Download Child and Adolescent Psychopathology

Chapter 1: Issues in
Diagnosis: Conceptual
Issues and Controversies
Scott O. Lilienfeld
Sarah Francis Smith
Ashley L. Watts
General Terminological Issues
 Classification Versus Diagnosis
 Classification: Overarching taxonomy
 Diagnosis: Act of placing an individual into a category within a taxonomy
 Signs Versus Symptoms
 Signs: Observable indicators (e.g., crying)
 Symptoms: Subjective indicators (e.g., feelings of guilt in depressed patient)
 Syndrome Versus Disorder Versus Disease
 Syndrome: Constellations of signs and symptoms that co-occur across
individuals
 Disorder: Syndromes that cannot be readily explained by other conditions
 Disease: Disorders in which pathology and etiology are reasonably well
understood
Functions of
Psychiatric Diagnosis
1. Diagnosis as communication

Distills information in a shorthand form that aids in
other professionals’ understanding of a case
2. Establishing linkages to other diagnoses
 Locates a patient’s problems within the context of more
and less related diagnostic categories
3. Provision of surplus information
 Generates predictions about case trajectory, response
to treatment, family history, laboratory research and so
on.
Misconceptions Regarding
Psychiatric Diagnosis
1. Mental illness is a myth
• Mental illness as “acute problems in living” (Szasz,
1960)
• Mental disorders cannot be clearly recognized by
corresponding lesions in the anatomical structure of the
body
• Rebuttal: Many medical disorders cannot be traced to
lesions and many lesions do not give rise to medical
disorders
Misconceptions Regarding
Psychiatric Diagnosis
2. Psychiatric diagnosis is merely pigeonholing
•
•
Diagnosing people with mental disorders deprives them
of uniqueness.
Rebuttal: Diagnosis merely indicates one way in which
people are alike.
Misconceptions Regarding
Psychiatric Diagnosis
3. Psychiatric diagnoses are unreliable
• Rebuttal: There are many kinds of reliability, which are
frequently discrepant with each other
• Evaluation of reliability hinges on the conceptualization
of a disorder (e.g., high test-retest reliability may be
expected for chronic disorders)
• Interrater reliability for most psychiatric diagnoses is as
high as that of other major medical disorders
(Lobbestael, Leurgans, & Arntz, 2011; Matarazzzo,
1983)
Misconceptions Regarding
Psychiatric Diagnosis
4. Psychiatric diagnoses are invalid
•
Simply descriptive labels for behavior we do not like
•
Rebuttal: Many psychiatric diagnoses provide surplus
information (e.g., schizophrenia)
Misconceptions Regarding
Psychiatric Diagnosis
5. Psychiatric diagnoses stigmatize people, and
often result in self-fulfilling prophecies
•
•
Lead to the interpretation of ambiguous behaviors as
consistent with the psychiatric diagnosis (e.g.,
Rosenhan, 1973)
Rebuttal: Incorrect diagnoses may lead to stigma, but
correct diagnoses may actually lead to reduced stigma
by providing an explanation for otherwise unexplainable
behavior (Ruscio, 2004)
What Is Mental Disorder?
 Statistical Model
 Disorder = Statistical Rarity
 No guidelines for cutoff between abnormality and normality
 Assumes all common conditions are normal (Wakefield, 1992)
 Subjective Distress Model
 Core feature of mental disorders is psychological pain
 In some ego-syntonic conditions, individuals do not see their behavior as
problematic (e.g., narcissistic personality disorder).
 Biological Model
 Disorder defined in terms of biological (or evolutionary) disadvantage to an
individual (e.g., increased risk for suicide in depressed patients) (Joiner, 2006).
 Some behaviors incur such disadvantage but are not disorders (e.g., military
combat). Some disorders do not incur long-term decrease in evolutionary fitness
but are disorders (e.g., phobias)
What Is Mental Disorder?
 Need for Treatment
 Disorder is any condition characterized by a need for medical intervention by a
health professional (Kraupl Taylor, 1971)
 Some conditions require medical intervention but are not disorders (e.g.,
pregnancy)
 Harmful Dysfunction
 Disorders are socially devalued (harmful) breakdowns of evolutionarily selected
systems (Wakefield, 1992)
 Many medical conditions are adaptive defenses (e.g., vomiting in the flu); many
psychological conditions are adaptive reactions to threat
 Roschian Analysis
 Concept of mental disorder is inherently fuzzy
 Mental disorders lack defining features and boundaries
 Controversies over concept of mental disorder are inevitable and unresolvable
Psychiatric Classification From
DSM-I to the Present
•
DSM-I and DSM-II
• DSM-I (APA, 1952): First clear attempt at describing major
psychiatric diagnoses in one manual
• DSM-II (APA, 1968): Similar in scope to DSM-I; greater detail
concerning signs and symptoms of disorders
• Major criticisms:
•
Low interrater reliability for many disorders
•
Influenced heavily by psychoanalytic concepts of disorders
•
Neglected consideration of contextual factors (e.g., cooccurring medical disorders)
Psychiatric Classification From
DSM-I to the Present
 DSM-III (APA, 1980) and Beyond
 Dramatic increase in coverage of disorders and detailed
guidelines for making diagnoses
 Standardized Diagnostic Criteria
• Signs and symptoms of each disorder explicitly delineated
 Algorithms and Decision Rules for Diagnoses
• Highly structured guidelines for number of symptoms and
combinations of symptoms that must be met for a diagnosis
 Hierarchical Exclusions Rules
• Rules to prevent diagnoses from being made if other diagnoses
better account for the clinical picture
Psychiatric Classification From
DSM-I to the Present
 DSM-III (APA, 1980) and Beyond
 Multiaxial Approach
• Evaluations along series of axes (e.g., Axis I – Major mental
disorders, Axis II – Personality disorders)
• Forced a holistic approach to diagnoses
• Dropped in DSM-5
 Theoretical Agnosticism
• Agnostic with respect to etiology of disorders
• Permits use of the manual by practitioners of many different
theoretical backgrounds
Psychiatric Classification From
DSM-I to the Present
 DSM-III-R and DSM-IV
 Retained major features/innovations of DSM-III
 Gradual move to a polythetic approach to diagnosis
 Led to increased heterogeneity of diagnoses
 Relaxation of many hierarchical exclusion rules (Pincus,
Tew, & First, 2004)
 DSM-IV added appendix for culture-bound syndromes
(e.g., koro)
Psychiatric Classification From
DSM-I to the Present
 DSM-5
 Published May 2013 (APA, 2013)
 Retained most of major categories of DSM-IV
 Dropped multiaxial system
 Attempted to decrease proliferation of new diagnoses by
necessitating rigorous validity data for new diagnoses
 Criticized for lowering diagnostic threshold for several
diagnostic categories (Batstra & Frances, 2012)
 Criticized for inadequate field trials focusing on clinical
feasibility rather than validity of new diagnostic categories
(Frances & Widiger, 2012)
Criticisms of Current
Classification System
 Comorbidity
 High levels of co-occurrence and covariation among many
diagnostic categories
 One disorder may lead to others; two disorders may mutually
influence each other or be different expressions of the same
underlying liability
 May result from overlapping diagnostic criteria or clinical
selection bias (du Fort, Newman, & Bland, 1993)
 Especially problematic for personality disorders (Widiger &
Rogers, 1989)
 Often underestimated in clinical practice
 May be attaching multiple labels to different manifestations of
the same condition
Criticisms of Current
Classification System
 Medicalization of Normality
 1. Increased number of diagnoses in DSMs
2. Lowered threshold for diagnoses in DSM-V (e.g., age of onset in
ADHD)
 May reflect splitting of broad diagnoses into narrower subtypes
(Wakefield, 2001) rather than increased coverage
 DSM-V also practiced lumping of narrower diagnostic categories into
broader ones (e.g., autism spectrum disorder)
 Neglect of the Attenuation Paradox (Loevinger, 1957)
 Efforts to achieve high reliability (especially internal consistency) may
decrease validity of psychiatric diagnoses
 Occurs when a narrow pool of items is used to describe a broad,
multifaceted construct
Criticisms of Current
Classification System
 Unsupported Retention of a Categorical Model
 DSM is exclusively categorical at measurement levelindividuals either meet a diagnostic criteria for a disorder
or not
 Growing evidence that many DSM diagnoses are
underpinned by dimensions rather than taxa (Kendell &
Jablensky, 2003)
 Measuring most disorders dimensionally almost always
results in higher correlations with external validating
variables (Craighead, Sheets, Craighead, & Madsen, 2011)
The DSM : Quo Vadis?
 Dimensional Approach
 Growing evidence for dimensionality of many psychiatric
conditions
 Many suggest using sets of dimensions from personality
science to aid in psychiatric diagnosis (Krueger et al., 2011;
Widiger & Clark, 2000)
• Five-Factor Model (FFM; Goldberg, 1993)
 Disagreement about nature and number of personality
dimensions to be used
 Distinction between basic tendencies and characteristic
adaptations is often neglected (Harkness & Lilienfeld, 1997)
 Personality dimensions may not be sufficient by
themselves to capture full variance in psychopathology
The DSM : Quo Vadis?
 Endophenotypic Markers
 Accumulating research on biochemistry, brain imaging,
performance on laboratory tasks and psychopathology
 Widespread assumption that endophenotypic markers are
more closely related to etiology than exophenotypic markers
(Kihlstrom, 2002)
 No endophenotypic markers of psychiatric diagnoses to date
come close to serving as inclusion criteria for respective
disorders
 May better serve as exclusion criteria
 Research Domain Criteria (RDoC): Proposed alternative to
DSM; goal is to identify psychobiological systems that underlie
psychopathology (Morris & Cuthbert, 2012) and markers of those
systems