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Ch 3. Diagnosis & Classification.pdf

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PSYC 3230
James Alcock

3. Diagnosis & Classification Monday, January 21, 2013 9:00 AM What is diagnosis? • What does it mean to "diagnose"? ○ A diagnosis is an identification of a condition or disease state ○ This is a medical notion that may or may not apply to psychological problems ○ Need a diagnostic system-- a collection of rules for guiding us in our determination of a diagnosis • [In psychiatry, a diagnosis is solely descriptive]  A "cold" is different from pneumonia in that…  Depression is different from anxiety What do we want in a diagnostic system? • Need descriptors that allow different clinicians to recognize the same disorder (reliability) • Need descriptors such that if present, they indicate the presence of a disorder, and if absent, the disorder is absent (validity) Diagnosis • Yet, that is not so easy ○ How do you know if someone is depressed?  Is it enough for someone to say "I am depressed?"  Does the person have to cry a lot or talk of suicide?  [Not all depressed people present with the same symptoms, there isn't one symptom that is necessary or sufficient]  Is loss of appetite a symptom, or poor sleep? ○ To answer such questions, someone must first define what depression is • Recall: ○ Hippocrates: beginnings of a diagnostic system ○ Kraeplin (19th century)  First comprehensive diagnostic system based on which characteristics occur together • 1948: World Health Organization ○ Extended "International List of the Causes of Death" to include psychological abnormalities ○ The list was renamed the International Statistical Classification of Diseases, Injuries, and Causes of Death (ICD) ○ Current: ICD-10 • 1952-- American Psychiatric Association published its own diagnostic system, the Diagnostic and Statistical Manual of Mental Disorders (DSM) ○ Diagnostic categories were:  Poorly defined  Heavily psychoanalytic-- manuals focused on unobservable internal states  Not based in empirical research  Did not involve objective criteria ○ Consequently, it was not very useful, and different clinicians would come up with different diagnoses for the same person • 1968: DSM-II ○ Suffered from many of the same problems as the original DSM • 1980: DSM-III ○ Radically different from DSM-II  Multi-axial classification-- rather than using a single label, client described in terms of a number of clinically important factors, or axes  Focus on descriptive features that allow identification of the problem rather than interpretation based on unvalidated theories  Provided detailed criterion sets for each disorder, to allow various clinicians to diagnose in a similar way  Attempted to be atheoretical; eliminated theory-laden terms such as "neurosis" (psychoanalytic) • 1987: DSM-III-R-- a minor revision • 1994: DSM-IV-- major revision, still using the multiaxial approach ○ Development team searched for an empirical basis for each disorder, and carried out extensive field trials using the classification system  Evaluated more than 6000 subjects, using hundreds of clinicians, looking at reliability and validity ○ Developers took more international approach; Cooperated with the developers of ICD-10 which is widely used around the world outside of North America • 2000: DSM-IV-TR-- relatively minor changes to text ○ Translated into French as well • For both the DSM and ICD (which will be discussed later), diagnoses are defined purely in terms of symptoms ○ Quite different from diagnosis in physical medicine ○ In physical medicine, data not available from the patient is gathered by tests-- blood tests, x-rays, etc. ○ Medical diagnoses adds new information about the disorder-- causation, course, treatment, etc. ○ [Psychological tests are descriptive and do not add new information, this is a huge misconception in psychology] • Yet, DSM provides some consistency so that when terms such as depression or anxiety are used, people are describing more or less the same problems • In DSM-IV, each mental disorder is conceptualized as: ○ "A clinically significant behavioral or psychological syndrome or pattern that occurs in an individual and that is associated with present distress (e.g., a painful symptom) or disability (e.g., impairment in one or more important areas of functioning) or with a significantly increased risk of suffering death, pain, disability or an important loss of freedom." (DSM-IV p. xxi)  Excluding simple deviance from societal norms  Excluding expected or culturally sanctioned responses-- as to the death of a loved one • In DSM-IV, NOT assumed that all categories are mutually exclusive, that there is no overlap ○ Because of the continuum between normal and abnormal functioning, often only need to fill a subset of conditions to warrant the diagnosis ○ Aim is to describe accurately the various disorders rather than interpret them Major Axes in DSM-IV • A
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