Science and Pseudoscience in Abnormal Psychology, Part III; Diagnosis & the DSM February 10, 2014...

Science and Pseudoscience

in Abnormal Psychology,

Part III;

Diagnosis & the DSM

February 10, 2014

PSYC 2340: Abnormal Psychology

Brett Deacon, Ph.D.

Announcements

• This week:

• Today: Diagnosing mental disorders and the DSM

• Wednesday: Rosenhan article

• Friday: Exam #1

On Being Sane in Insane Places

(Rosenhan, 1973)

http://www.youtube.com/watch?v=Kq-7uvVOoyk



“It is clear that we cannot distinguish

the sane from the insane in

psychiatric hospitals.”

-D.L. Rosenhan

Diagnosis and Stigma

• On being sane in insane places (Rosenhan, 1973)

• Issues to consider in the article

• (1) how diagnoses were made

• (2) the effects of being labeled with a diagnosis

• (3) the effects of being a patient in a mental institution

• (4) your personal reaction to the study

From Last Class

• Naïve realism and the accuracy of subjective impressions (intuition)

• My debate with EPA president about antidepressant efficacy

• Second half of Scott Lilienfeld’s presentation

Important Points

• Pseudoscientific therapies are popular• In part, their popularity is due to the romantic

“way of knowing” (as opposed to empiricism)• Romantics endorse naïve realism and fall prey

to confirmation bias• Scientific thinking is unnatural

• Scientists should be humble • Scientific training – thinking like a scientist vs.

learning scientific technologies• Last few slides

Causes of Spurious Therapy Effectiveness

• Name reasons why a client might appear to improve during therapy – other than the direct effects of the therapy itself.

Causes of Spurious Therapy Effectiveness

• Placebo (expectancy) effects

• Spontaneous remission

• Regression to the mean

• Demand characteristics

• Maturation

• Absence of knowledge of the hypothetical counterfactual

Ethics, Science, and Pseudoscience

• APA ethics code (http://www.apa.org/ethics/code2002.html#general)

• Principle A: Beneficence and Nonmaleficence

• “Psychologists strive to benefit those with whom they work and take care to do no harm. In their professional actions, psychologists seek to safeguard the welfare and rights of those with whom they interact professionally and other affected persons.”

http://www.apa.org/ethics/code2002.html

Exam Review

• Chapter 1 (Intro and Historical Context)

• Defining abnormality, mental disorder, insanity, and disease

• DSM-IV and diagnosing mental disorders

• Differences between mental health professions

• Scientist-practitioner model

• Historical conceptions of psychopathology (supernatural, biological, psychological)

Exam Review


• Assumptions of the modern biological approach,

classifying psychotropic medications and

understanding drug action, chemical imbalance

theory

Exam Review


• Psychoanalytic theory

• Humanistic theory• Assumptions of scientific approach to

psychotherapy research vs. humanistic philosophy

• Behavioral and cognitive theory (classical and operant conditioning, cognition)

Exam Review

• Costs of pseudoscientific therapies

• Lilienfeld talk• Romantic vs. empiricism• Reasons why what we think is so might not be

• Importance of science in abnormal psychology

Exam Review

• Rosenhan article• Arguments, and responses from critics

• The anti-psychiatry movement

Exam Review

• Chapter 3 (Diagnosis; pp. 85-96 only)

• Categorical, dimensional, and prototypical approaches to classification

• Advantages and disadvantages of diagnosing

• Reliability and validity in diagnosis

• Characteristics of previous and current versions of the DSM

Diagnosing Mental Disorders

and the DSM


• Diagnostic classification

• Classification is central to all sciences

• Develop categories based on shared attributes

• Controversial when applied to abnormal

psychology

Classification

• Scientific classification strives to “carve nature at its joints”

• Seeks to identify “natural categories”

• Examples of natural categories of medical diseases: tuberculosis, hepatitis, influenza, HIV/AIDS

• Not all medical problems are natural categories

• Hypertension, obesity, etc.

Classification and Natural Categories

http://www.flickr.com/photos/rainriver/1830570104/

Issues in Diagnosing Mental Disorders

• Natural vs. artificial categories

• Are mental disorders distinct entities that can be meaningfully (validly) classified into different categories?

• Does nature have “joints” that represent different mental disorders?

• Do mental disorders represent natural categories?


• Mental disorders are not valid, in the sense that

there is no objective test for them

• Mental disorders are “fictive categories” or

“heuristics” not to be misconstrued as “natural

kinds” or “real entities” (former NIMH Director

Steven Hyman)


• Does this mean that psychological problems do

not exist?

• Is schizophrenia a “myth” (Szasz, 1961)?

• Validity issues aside, are there advantages to

classifying mental disorders?

Classification and Natural Categories: Analogy to Mental Disorders

Classifying Psychopathology

• Categorical (classical) approach

• A person either has a disorder or does not

• Assumes each disorder has a clear underlying cause (most likely biological)

• Assumes each disorder is fundamentally unique

• Everybody with the disorder should meet all diagnostic criteria


• Dimensional approach

• People have varying degrees of psychopathology

• Dimensions can overlap with each other

• Does not assume the presence of pathology



• Advantages: it is accurate• Research shows that many mental disorder

symptoms (e.g., depressed mood, obsessions and compulsions) are continuous, not categorical

• No need to assume people with problems are abnormal, defective, or fundamentally different from others



• Disadvantages: • What are the dimensions? How many are

there? How to rate them? What to do with these ratings? What would third-party payers do with these ratings?

• Nobody has ever generated a clinically useful dimensional system of classification


• Prototypical approach

• 1. Identifies essential characteristics of a disorder

• 2. Allows for variations within the diagnosis

• Diagnostic criteria include a number of symptoms, only some of which need to be met

• Combines elements of categorical and dimensional approach, but in the end a person either has or does not have a disorder

• Exemplified in the DSM


• 1. Problems are diagnosed based on symptoms without regard to their cause


• Do all people who meet DSM diagnostic criteria for major depressive disorder have the same problem?

• Person A: homesick college student

• Person B: terminally ill cancer patient

• Does the cause of a problem matter if we wish to understand and treat it?


• 2. Excessive variation within the same diagnosis

Diagnosing Obsessive-Compulsive Disorder

• The following people all have the same diagnosis:• Patient #1: hoarding worthless objects

• Patient #2: contamination fear and washing rituals

• Patient #3: fear of stabbing others with knife

• Patient #4: fear of hitting pedestrians with car

• Patient #5: symmetry and arranging compulsions

• Patient #6: blasphemous obsessions and compulsive

religious rituals


• 3. Excessive overlap between different diagnoses

Comorbidity Exemplar: Major Depressive Disorder and Generalized Anxiety Disorder

• Common symptoms:• Physical agitation/restlessness• Fatigue/loss of energy• Difficulty concentrating• Irritability• Sleep disturbance

• Extremely high comorbidity

• “All depressed patients are anxious, but not all anxious patients are depressed” (your text)

Purposes and Evolution of the DSM

• Diagnostic and Statistical Manual of Mental Disorders (DSM); published by American Psychiatric Association

• DSM-I (1952) and DSM-II (1968)

• Both relied on unproven theories and were unreliable

Diagnostic Criteria for “Phobic Reaction” in DSM-I (1952)

Evolution of the DSM

• History of the DSM

• 5 editions, I in 1952 through IV in 1994

• DSM-I (1952)

• DSM-II (1968)

• DSM-III (1980)

• DSM-III-R (1987)

• DSM-IV (1994; “Text revision” in 2000)

Number of Diagnoses in the DSMs Across Editions (1952-1994)

DSM-I DSM-II DSM-III DSM-III-R DSM-IV0

50

100

150

200

250

300

350

400

# D

iagn

oses

The Modern DSM

• DSM-III (1980), DSM-III-R (1987), DSM-IV (1994)

• Atheoretical, emphasizing clinical description

• Detailed diagnostic criteria for each disorder

• Checklist approach to diagnosis

• Improved reliability for most disorders

• Problems include low reliability for some

disorders and reliance on committee

consensus

The Modern DSM

• Paradigm shift from DSM-II to DSM-III (1980)

• From vague, psychoanalytic model to

atheoretical, symptom checklist

• This shift was not precipitated by advances in

scientific understanding of mental disorders

• Why did it occur?

Atheoretical Diagnosis

• Diagnostic criteria focus on symptoms, not on their presumed underlying causes

• Improves diagnostic reliability

• Fosters checklist approach to diagnosis

• Discourages attempts to understand the factors that are contributing to symptoms

• Basic characteristics• Multiaxial approach to diagnosis• Five axes describing full clinical presentation

The DSM-IV (1994)

• Axis I – Most major disorders

• Axis II – Stable, enduring problems (e.g., personality disorders, mental retardation)

• Axis III – Medical conditions related to abnormal behavior

• Axis IV – Psychosocial problems

• Axis V – Global clinician rating of adaptive functioning (Global Assessment of Functioning, or GAF)

The DSM-IV

The Case of Jenny

Jenny, a 21-year-old nurse, has mild asthma. She

worries that shortness of breath signifies an impending

episode of suffocation and death. When she has

difficulty breathing, she often experiences severe panic

attacks during which she is convinced she is dying. She

was referred to a psychologist after numerous ER visits,

unsuccessful medication trials, and relaxation training.

She frequently misses work because of her panic

symptoms and is in danger of being fired if she takes

any more sick days.

Jenny’s DSM-IV Diagnosis

• Axis I: Panic Disorder with Agoraphobia

• Axis II: No diagnosis

• Axis III: Asthma

• Axis IV: Occupational problems

• Axis V: GAF = 55 (Current)


• Primary role of mental health professionals

• Scientifically questionable but practically indispensable in our current healthcare system

Reliability and Diagnosis

• Reliability (interrater agreement). Affected by:

• Subjectivity of diagnostic criteria

• Patient report (accuracy, self-disclosure)

• Types of questions being asked by assessor

• Unstructured vs. structured interviews

Reliability and Diagnosis

• Diagnosing ADHD http://www.behaviorismandmentalhealth.com/2014/01/24/dr-lieberman-still-passing-the-buck/

• APA President Jeffrey Lieberman: ““…clinicians must resist marketing pressures, as well as parental pressures, to ensure that diagnoses are made in a rigorous way and that treatments are prescribed judiciously.”

• So, diagnoses are to be made in a rigorous way. Could anyone explain to me how the criterion item “Often runs or climbs about in situations where it is inappropriate (Note: in adolescents or adults may be limited to feeling restless)” can be applied in a rigorous way? How often is “often”? How would one even begin to assess the frequency with which a child runs or climbs about? How do we define appropriate? A strict, uptight nanny might say that running and climbing about is never appropriate. A parent or teacher might feel that running and climbing about were OK for boys but not for girls, etc… And apparently adolescents and adults score yes on this item if they often feel restless! I would guess that during the winter, half the adult population of the northern United States feel restless. We call it cabin fever! And aren’t adolescents supposed to feel restless? Isn’t it the time of the great awakening – when young people look to the horizon and dream their dreams?

http://www.behaviorismandmentalhealth.com/2014/01/24/dr-lieberman-still-passing-the-buck/

http://www.behaviorismandmentalhealth.com/2014/01/24/dr-lieberman-still-passing-the-buck/

Validity and Mental Disorders

• Mental disorders overlap a great deal and are not separated by “natural boundaries”

• We have no objective tests to detect them

• Mental disorders are not categorically distinct from normality (i.e., mental health problems exist on a continuum)

• Thus, mental disorders are not valid in the traditional sense

• They are, however, useful by virtue of conveying information about cause, outcome, and treatment (Kendell & Jablensky, 2003)

Advantages of Diagnosing

• Enhances communication between professionals

• Facilitates study of causes and treatments of specific disorders

• Helps in treatment planning

• Necessary for insurance reimbursement

Disadvantages of Diagnosing

• Adds little to our understanding of a problem

• Many diagnoses have poor reliability

• Stigmatizes patients and invites discrimination

• Suggests the presence of a disease state

Science and Pseudoscience in Abnormal Psychology, Part III; Diagnosis & the DSM February 10, 2014...

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