What is a diagnostic system?
- a classification system based on rules used to organize and understand diseases and disorders
- categorize them based on clusters of symptoms.
- a certain set of symptoms that only exist for a given disorder.
- outlines decision-making rules for determining diagnoses based on presenting symptoms.
- allows us to make
Why do we diagnose?
- communication: esp. in hospitals- working with multiple people such as nurses, psychiatrists, surgeons, etc., so it is important for them to know everything.
- it helps facilitate research: how things happen, why they happen- if you have a co-occurring diagnosis, research can help us isolate.
- provides a common language and a concise description of the client’s condition
- suggests possible comorbidity, prognosis
- facilitates research by defining experimental groups.
- can investigate potential etiological factors
- suggests potential treatments
- often required to determine eligibility or programs such as for insurance
- can give them diagnoses of MDD (NOS- not otherwise specified) which says there sn;t exact diagnoses, but they don’t meet the criteria, but they do have some sort of label & need insurance.
drawbacks of diagnoses
- ▫ Stigmatization
▫ Potential impact on self-concept
▫ Inaccurate diagnosis = inappropriate treatment
▫ Limitations of current diagnostic systems - categorizing people and forcing them to fit into something.
- experienced psychologists sometimes assume to put people into categories they’re most familiar with (tunnel vision)
- no room for thinking outside the box.
- all psychologists might not give the same diagnoses.
First diagnostic system- who created it?
- Kraeplin created it
- he looked at Dementia praecox (schizophrenia) vs. manic-depressive insanity (bipolar disorder)
- this built the foundation for modern psychiatric diagnostic systems (he started the system- by making cateogires that helped us differentiate between disorders)
- diagnoses as medical illnesses; you can have suicidal ideation but not be depressed, and vice versa.
- use specific criteria to define categories
- emphasis on diagnostic reliability
What does prototype model mean?
- diagnostic system outlines a prototype
- clients may differ in the degree to which they match the prototype
- people with the same diagnosis may have different symptoms and may require different treatments
- more of an issue with certain diagnoses.
- boys & girls are different in how they present their ADHD(get underdiagnosed) -they can have same diagnoses, but how it manifests in you can be different.
DSM: what is it?
Diagnostic and Statistical Manual of Mental Disorders
- Diagnostic system used by many North American mental health professionals
- DSM DSM-II DSM-III DSM-III-R DSM-IV DSM-IV-TR DSM-5DSM-5-TR
- made by psychatrists
DSM 5: what is it
- began planning in 1999
- working groups set by 2008
- finalized information and criteria for each diagnostic category
- reviewed data from field testing
- solicited feedback from stakeholders
- released 2013
- psychology changes- more updates- downfall- expensive updating
- About 10% more diagnoses (approx. 330)
- Categorical
- Research base inadequate to support dimensional approach - Clusters of similar disorders
-Meant to reflect underlying dimensions
Lifespan approach
Aims:
-Effort to maintain continuity
-Revisions to be based on scientific evidence
-Manual to be feasible for use
DSM-5- TR & what were the major changes?
- released March 2022
- Revised text for almost all disorders with updated sections on associated features, prevalence, development and course, risk and prognostic factors, culture, diagnostic markers, suicide, and differential diagnosis.
- addition of the new diagnosis of prolonged grief disorders to Section II
- over 70 modified criteria set with helpful clarifications since the publication of DSM-5
- fully updated “introduction” and “use of the manual” to guide users and provide context for important terminology.
- consideration of the impact of racism and discrimination on mental disorders integrated into the text.
What are the features of the DSM-TR
- provides information on:
- diagnostic features
- subtypes
- associated features and disorder
- prevalence
- course
- familial pattern
- differential diagnosis
- culture, age, and gender features
*alerts the clinician to important information that should be considered.
- shouldn’t always be black & white0 gives supporting evidence.
- if only using DSM for everything, then you’re not doing your job as a clinician.
Is there more or less focus on culture considerations in DSM-TR?
Yes, focuses more on ethnic and cultural considerations.
- Important for validity and relevance
- Considers ethnic and cultural factors relevant to each diagnosis
- Cultural syndromes included in the appendix
- Section on the cultural formulation
- Identity, explanations, factors relevant to the environment, functioning, therapeutic relationship
- Increase cultural sensitivity, appropriateness of clinical formulation
- However, it is not perfect because culture is very diverse; everyone’s interpretation of their own culture is different. Culture is complex - just having black & white diagnostic system isn’t enough.
Which DSM is the most controversial?
- DSM 5
- Increase in public and professional scrutiny
- Concerns with validity of diagnoses, impact on diagnosed
- Spitzer decried lack of transparency
- Negative reaction to proposed changes
- Over-representation of medical/biological views on disorders and their treatment
- Conflict of interest
- Resignation of personality disorders work group members
- Very poor results in field trials
What do health care providers use
- Healthcare providers covered by HIPPA (Medicaid and Medicare) are required to use the ICD (international)
- NIHM announced that they will not fund research based on DSM-5 diagnostic categories
- Lack of validity data
-Encouraging development of a new diagnostic system based on biological markers
what are some controversial changes made in DSM
- Pathologizing bereavement
- Disruptive Mood Dysregulation Disorder
- Mild Neurocognitive Disorder
- Binge Eating Disorder
- Autistic Spectrum Disorder
- Substance Use Disorders (rather than Abuse and Dependence)
- Behavioral Addictions (gambling, exercise addition)
What is ICD
ICD = International Statistical Classification of Diseases and Related Health Problems
- Internationally used diagnostic system
- Main alternative to the DSM
- Developed by WHO
- Classification of all health conditions
- Section on mental and behavioral disorders
What is the ICD-11?
- First edition 1948
- Most recent edition released in 2019
- Over 300 disorders
- International development and field testing
- Available online, updated annually
- Free
- Clinical modification (ICD-CM) provides greater precision about each diagnosis and person’s condition
ICD relation to the DSM
- ICD-CM broadly compatible with DSM-5-TR
- Each diagnosis in DSM-5 –TR includes ICD numerical codes
- Are some differences in:
- Diagnostic classes
- specific diagnoses
- how some diagnoses are described and conceptualized - Updated ICD-10-CM codes implemented since 2013, including over 50 coding updates new to DSM-5-TR for substance intoxication and withdrawal and other disorders
Limitations (what are a couple of limitations of the DSM-5- give examples)
- Defining Abnormality
- what defines abnormality is somewhat individualistic.
- Concerns with over-diagnosis
- “medicalization of ordinary life”
- Has to exceed defined normative behaviour
- However, even with mild disorders associated with disability, the risk of impaired functioning - Diagnostic Reliability
- Inter-rater reliability often falls below acceptable levels
- Bigger concern for uncommon conditions
- Better if focus on major categories, if ↑ time with the client, look at well-trained clinicians, use structured interviews - Heterogeneous Symptom Profiles
- Most disorders are polythetic
- Can have different symptoms and receive the same diagnosis
- Affects inter-rater reliability and has treatment implications
- Subtypes generally don’t fix the problem - Diagnostic Validity
- Disorders should be discrete and have clear boundaries
- Applies to very few mental disorders
- Diagnosis should predict prognosis, treatment outcome, etiology etc. - Comorbidity
- Rates often exceed 40% (most people meet criteria for more than 1) (maybe they won’t meet criteria but has impairing symptoms)
- ↑ impairment, chronicity, health problems, service use
- Affects research and clinical service
- Categorical vs. dimensional classification
- Multiple bases for making diagnoses
- Development is influenced by politics
- Potential for bias
What are the differences between categorical classification & continuous?
categorical: differ in type
- you either have the disorder, or you don’t
- those within a category should be similar to one another
continuous (aka dimensional) - differ in degree
- can have more or less of a characteristic or property
- can arrange on a continuum
- assess individuals on important dimensions of functioning
- dimensions reflect higher-order constructs (e.g., neuroticism, externalizing problems)
- dimensions may relate to one another.
What are some examples of continuous & categorical models?
Continuous:
- dimensional models
- Achenback: externalizing problems vs. internalizing problems
- Achenbach system of empirically based assessment
personality disorders
- draft version of DSM-5
- rate clients on a number of dimensions
categorical models
- DSM
- ICD
What are some arguments for Dimensional classifications? (continuous)
- abnormal behaviour is typically not qualitatively differnt from normal behaviour
- broader dimensions may better represent the nature of mental disorders
- DSM-5-TR acknowledges that categories need not be discrete
- easy to confuse categorization with explanation (g.g., OCD)
- high rates of comorbidity
- rise in transdiagnostic treatments is consistent with the dimensional approach.
What are some arguments for categorical classification?
- there are no commonly agreed upon dimensional systems that could replace the current diagnostic systems.
- clearly defined categories increase diagnostic reliability
- it can be difficult to establish a reliable and valid dimensional system (e.g., personality disorders in DSM-5).
- categories instantly communicate important information.
- typically presentation- potential treatments etc.
- this one is clear, and in front of me, I should treat it and see symptom reduction, then I can move on to the next disorder.
- order: sometimes, the order of treating something should be taken into consideration.
- Categorical approaches mirror the diagnostic systems used in medicine
what are the benefits of using both categorical and dimensional models (continuous)?
Santor and Coyne (2001)
- can express the severity of depression on a continuum
- there are real group differences between ‘depressed’ and ‘distressed’ but non-depressed
- depressed mood
- anhedonia
- suicidal ideation
- somatic symptoms
- distress as continuous and disorder as categorical
What causes mental disorders?
- Etiological models vary depending on theoretical orientation
- Biopsychosocial model
- Mental disorders determined by a blend of biological, psychological, and social factors
-Contribution of each varies across disorders
- Contribution may vary across the lifespan
- Contribution may vary across cultures
Stress
- May contribute to onset of mental disorders
- Odds of developing a disorder increases with number of stressors
- Interpersonal stress model
- Intergenerational transmission
- Depression in maternal grandmother → depression and interpersonal stress in mother → decreased social competence and high interpersonal stress in children → depression in children
What is the diathesis-stress model?
Diathesis-Stress Model
- Diathesis = pre-existing vulnerability
- Diathesis is necessary but not sufficient
- Diathesis + stress = disorder
- Both diathesis and stress are on a continuum
- Stress can be environmental, biological, interpersonal, or psychological
- Diathesis can influence perception of stress, exposure to stressors
- Particularly relevant to understanding depression
- Negative childhood experience = negative schemas
Stressful events activate
