lecture 1 - what is normal? Flashcards

Question

Differences between DSM-V and ICD-11

Answer 1

DSM has been the system most widely used in research whereas, outside the US, ICD was the preferred classification system used by psychiatrists in clinical practice (Clark et al, 2017; First et al, 2018). There has been close collaboration between both organisations, the World Health Organisation and the American Psychiatric Association, in the development of their respective systems since 1978, with the aim of ‘harmonising’ both. For the latest iteration of ICD, both groups formed an ICD-DSM Harmonisation Group, whose main focus was on reaching agreement in the grouping of disorders so that any differences were deliberate rather than accidental or avoidable. Some deliberate differences remain. The groupings, or meta-structure, were summarised by First et al (2021) and you can see a comparison between ICD-11 and DSM-V in Table 17.2a and b. The newest version of the ICD (ICD-11) was adopted in April 2019 and while it is separate to the DSM, both share similarities, some differences in emphasis, and some very obvious differences in what each includes at the disorder and definition of disorder level. A comprehensive review of the similarities and differences in diagnostic criteria by First et al (2021), for example, found that although agreement between ICD-11 and DSM-5 was greater than between ICD-10 and DSM-IV, ICD-11 contained 19 disorders that did not appear in DSM and DSM contained seven disorders not included in ICD. Of the 103 diagnostic entries in both systems, 19.4 per cent (20) were judged to feature major differences, 10 per cent featured minor differences, 40.8 per cent (42) featured minor differences in definition and 30 per cent (31) were virtually identical. Eleven disorders in ICD-11 are ‘new’, that is, they did not appear in previous editions. Compare this with DSM-V which proposed very few new categories largely because of the criticism it received after the publication of DSM-IV and its proliferation of new disorders. ICD-11 also allows the same disorder to appear under more than one diagnosis, but it is listed as primary where it is the major disorder. Two disorders added to DSM-V which do not appear in ICD-11 include Social (Pragmatic) Communication Disorder (previously known as pervasive Developmental Disorder Not Otherwise Specified, now dropped) and Disruptive Mood Dysregulation Disorder: neither were considered to have a strong enough evidence base to be included in ICD as a separate diagnosis. The criteria for autism spectrum disorder are similar but DSM provides three prescriptive lists of symptoms for social communication problems whereas ICD indicates that the individual may manifest one of seven behaviours (which are characteristic of DSM’s three principal symptoms). Similarities are also seen for Attention-Deficit Hyperactivity Disorder, but DSM lists a specific set of nine symptoms, six of which must be manifested in adults, whereas ICD lists two groups of symptoms and individuals must manifest at least one symptom from each group

Answer 2

For example, the minimum required duration of symptoms in ICD is one month and in DSM it is at least six months, the rationale (in the ICD’s case) being that earlier intervention leads to a better outcome. DSM includes schizophreniform disorder (which is of at least one month’s duration) but this does not appear in ICD. Both require a minimum number of symptoms to be present for at least month, but ICD adds ‘experiences of influence, passivity or control’, that is, having thoughts controlled by others, having their thoughts removed, and having thoughts inserted. DSM describes these as delusions, but ICD reserves the word delusions for the beliefs that may arise from these experiences. ICD lists alogia (lack of speech), asociality and ahedonia as negative symptoms but does not, as DSM does, list a deterioration in work and relationships as a symptom. The systems also differ in how they measure the severity of different types of symptoms. In ICD, there are six symptom domains, one of which is positive symptoms; DSM includes three symptom domains captured by this one domain. ICD has a four- point scale (not present, mild, moderate, severe); DSM has five (not present, equivocal, mild, moderate, severe).

Answer 3

the individual must experience at least five symptoms every day for two weeks and one is depressed mood or lack of pleasure/interest (First et al, 2021). ICD lists 10 symptoms; DSM lists nine; ICD includes ‘hopelessness about the future’ as it considers this to be highly predictive of the disorder. There is a difference in how the systems consider depression following bereavement. This is a normal process in response to the death of a loved person, but persistent and continued depression might signify a more serious, protracted disorder. DSM provides guidance on what might constitute depressive symptoms not related to bereavement, but ICD does not consider depressive symptoms experienced during grief to be the same as other depressive symptoms. ICD also has a separate diagnostic category, Dysthymic Disorder, characterised by depressive symptoms experienced for most days but does not constitute a major depressive episode. The two systems agree that in anxiety, the feeling must persist for more days than not, but DSM requires a minimum duration of six months and ICD ‘at least several months’. ICD, unlike DSM, also includes ‘free-floating anxiety’ as a symptom, anxiety that cannot be attributed to any known cause, a symptom that has been included partly because patients are unable to identify the cognitions that lead to their experiencing anxiety.

Answer 4

a preoccupation with the fear of developing illness – whereas DSM subsumes this under ‘Somatic Symptom Disorder or Illness Anxiety Disorder’. Somatic Symptom Disorder replaced somatisation disorder and has three categories of symptoms, A, B and C. A level criterion requires a distressing somatic symptom, B level involves serious thoughts about the symptoms and excessive energy spent on worrying about these symptoms, and C level requires the symptoms to have been experienced for over 6 months. The disorder has good reliability and the response to its inclusion in DSM has been positive (Lowe et al, 2021).

Answer 5

DSM includes one category for post-traumatic stress disorder (PTSD); ICD includes PTSD and Complex PTSD, the latter describing a pervasive stress response that can affect relationships and how negatively the person views themselves. Both ICD and DSM list a core set of symptoms including intrusive thoughts, avoiding stimuli associated with the traumatic experience and changes in arousal. DSM includes a negative change in mood and thinking as a core symptom, but this is subsumed in the CPTSD category in ICD. Events causing trauma are broadly defined in ICD (‘ extremely threatening or horrific nature’) but more specifically so in DSM (‘exposure to actual or threatened death, serious injury, or sexual violence’). First et al suggest that this reflects DSM’s concern that the PTSD category might be abused by those wishing to exploit the disorder. Research suggests that the use of ICD criteria lead to lower prevalence rates than the use of DSM and that the systems may not identify the same individuals (Shelvin et al, 2018).

Answer 6

(Billieux et al, 2021). DSM did consider including internet gaming disorder, as a result of the growth in gaming and online gaming. Billieux et al raise a criticism that was levelled at DSM-IV that there is a danger the diagnosis might lead to a pathologising of gaming. However, a Delphi study in which experts were asked to judge the validity of the criteria used in the diagnosis of gambling disorder, concluded that the guidelines could successfully identify problem gambling without pathologising gambling in general (Castro-Calvo et al, 2021). There are some subtle differences in the diagnostic criteria for eating disorders. Both require frequent and persistent episodes of binge eating as core symptoms of bulimia nervosa or binge-eating disorder but they define binge eating differently: DSM requires that the amount of food eaten in an episode is larger than what most people eat; ICD requires that the individual eat more than usual (First et al, 2021). Signifiant differences exist in the consideration of substance use disorders with ICD listing specific substances including NMDA (found under hallucinogen class in DSM), cocaine (included under stimulant class in DSM) and cannabinoids (under cannabis class in DSM). Some disorders are included on the basis of the pattern of use including one episode of harmful use, persistent episodes of harmful use and dependence (having no control over use). DSM has one category: Substance Use Disorder. One final difference, although not the only one, concerns the system’s diagnoses of paraphilias. ICD now distinguishes between disorders than involve non-consenting others (there are five categories) and behaviour which involves solitary behaviour or behaviour with a consenting other, to prevent the pathologising of sexual behaviour that differs from the norm. ICD includes a specific category for the latter if the behaviour includes risk of harm or distress

Answer 7

The DSM is not short of critics. Frances and Widiger (2012) argued that ‘our classification of mental disorders is no more than a collection of fallible and limited constructs that seek, but never find, an elusive truth’. However, they go on: ‘Nevertheless, this is our best current way of defining and communicating about mental disorders,’ The principal criticism of the new DSM (and some of the old ones) is that it has been overly keen to introduce new mental disorders on the basis of, in some cases, very little evidence; no data on prevalence, validity, reliability, treatment response and so on has been included (see Maj, 2014; Lasalvia, 2015; Stein and Nesse, 2015 for some lively arguments). Until DSM-III, homosexuality was included as a mental illness. Frances and Nardo (2013) provide two examples of disorders which may not merit inclusion. ‘Binge-eating disorder’, for example, is described as a mental disorder where a person binge eats once a week for three months. Whether this behaviour, which some might consider not exactly abnormal, constitutes a serious mental condition is arguable. DSM has also pathologised what some have described as normal behaviour: children’s temper tantrums (which are now described as ‘disruptive mood dysregulation disorder’). Grief is another behaviour which has been pathologised. Houts (2001), one of DSM’s fiercest critics, refers to sleep disorders as an example of this invention and over-inclusiveness. Until DSM-III-R, sleep disorders were not considered mental disorders. ‘It is as though sleep problems became mental disorders overnight sometime in 1987’, he notes. Other behaviours which Houts argues were inappropriately classed as mental disorder at the time include frotteurism (touching or rubbing up against another in a sexual way without consent), kleptomania (compulsive theft), dyscalculia (a disorder of mathematical thinking), pathological gambling and voyeurism. Critics, even those involved in chairing previous DSM revisions, such as Allen Frances, have offered excoriating assessments of this new set of diagnoses (you can find his objections here: www.huffingtonpost.com).

Answer 8

Another issue with classification is the potential of overdiagnosis or attaching a diagnosis of mental illness to a behaviour which would otherwise not have been so-described, even by those describing symptoms. Moffitt et al (2010) found that over a 15-year period, diagnosis of anxiety disorder had increased by 50 per cent, depression by 41 per cent, alcohol dependence by 38 per cent and cannabis dependence by 18 per cent. A study of 1,420 individuals assessed nine times between the ages of 9 and 21 found that 61 per cent of them met well-defined criteria for mental illness (Copeland et al, 2011). Other conditions which have seen a rise in diagnosis in the past 15 years include autism (20-fold increase), ADHD (tripled) and adult bipolar disorder (doubled). Antidepressant medication is the third most popularly prescribed medication in the US, especially in the 18–44-year-old group (Pratt et al, 2011); this either reflects a genuine response to a genuine condition or an over-prescription. The US does report the highest prevalence of mental illness and the greatest severity of illness than any other major country: bipolar disorder is 4.4 per cent in the US, twice as high as that reported in other countries (Deacon, 2013). Reflecting the fact that the DSM-V is strongly influenced by psychiatrists, the manual tends to be more consistent with the medical perspective on mental disorders. This means that diagnosis and treatment based on the DSM-V emphasise biological factors, and equate mental illness with physical illness which may, in turn, mean that potential cognitive and environmental determinants may be overlooked. The current revision is partly driven by the US’s National Institute of Mental Health which views mental disorders as diseases and whose new framework for undertaking mental health research is focused on discovering the neurobiological mechanisms which underlie mental illness (Kirmayer and Crafa, 2014) and on creating a diagnostic system based on neural, biological measures.

Answer 9

Although DSM argues that its diagnostic criteria and classifications are based on neurobiological research, there are few consistent neurobiological correlates of the disorders contained within it. Some have noted that a biological test does not appear as a criterion for diagnosis in any DSM disorder (Deacon, 2013). Even the measures used to derive these correlates might present us with confounds. A person with autism, for example, responds to the experience of undergoing an fMRI scan (one of the principal measures of brain activation) differently to a person with schizophrenia (Weinberger and Goldberg, 2014). Other authors have pointed out that DSM’s own methods did not provide some support for the existence of certain types of mental disorder. For example, the DSM field trials used a statistic called kappa to ensure that agreement between two clinicians on the diagnosis of a disorder was sound and consistent. If an illness appears in 10 per cent of patients in a clinic, and two clinicians agree that the same diagnosis can be confirmed in 85 per cent, the kappa value of this is 85 (Freedman et al, 2013). The kappa value for schizophrenia in DSM-IV, for example, was 85 per cent, that is, high. It is also high for bipolar disorder, a condition called schizoaffective disorder, post-traumatic stress disorder (67 per cent), major neurocognitive disorders and hoarding disorders. Major depression, which has not changed substantially since DSM-IV, presents more of a problem because its symptoms can vary from mild to severe and from those who seek treatment to those who are disabled by the illness. But depression also co-occurs with anxiety; in the jargon, it is ‘co-morbid with’. Personality disorder is another illness which performed badly in terms of kappa results; while agreement on the diagnosis of borderline personality disorder was good, antisocial personality disorder and obsessive-compulsive personality had questionable reliability; narcissistic personality and schizotypal personality disorders appeared so infrequently that they could not be evaluated.

Answer 10

* The DSM has a problem with reliability, which means what it did in the context of psychological testing consistency across applications. * If the DSM was perfectly reliable, users would be able to diagnose each case in the same way. But evaluating psychological disorders is not so easy. * Using the DSM is more like navigating through an unfamiliar city using only a crude map and using this map you may not find your destination. * Mental disorders do not have distinct borders that allow a mental health professional to diagnose a disorder in a person with 100 per cent accuracy all of the time. * Some critics argue that DSM encourages the making of false-positive judgements, claiming a disorder exists when there only exists a moderate, normal disruption in behaviour. Eg one in four cases of bereavement might be diagnosed as major depressive disorder when these people are undergoing a natural, event-specific change in mood - wakefield and first 2012 * Evidence suggests that actuarial statistical analysis of symptoms is better than clinical analysis (Egisdottir et al 2006) * Specific indicators such as sex, age, test scores, and medical history are superior to expert ‘experience’ and knowledge of previous cases. * The actuarial method was used to assess how long a person would live (using statistics such as age, sex, height, weight etc) and to set levels of insurance. * Not every individual will follow the pattern predicted by these statistics but as a general guide they are a useful statistical predictor of groups of people's behaviour as a whole. * The actuarial method is 13% more accurate than the clinical method - found by egisdottir et al's (2006) meta-analysis. * Reasons for the success include its reliability - a decision is based on the same criteria and not based on the subjective impression of the clinician who may be influenced by irrelevant variables or not pay attention to relevant ones. * Most clinicians, however, adopt the clinical method, despite the advantages of the actuarial method. * People are always more persuaded by the importance of narrative than the importance of statistics. Another criticism of DSM is that by giving a diagnosis of mental illness, the individual carries a formal signal of stigma. People respond negatively to those with mental illness, and the evidence for this and what we might do to change this behaviour is considered next.

Answer 11

* Labelling can lead to a perception of a person that is based solely on the label and the characteristics associated with it and their behaviour will probably be perceived selectively and interpreted in terms of the diagnosis. * In an experiment by Langer and Abelson (1974), illustrated how labelling can affect clinical judgements. psychoanalysts were shown a videotape of a young man who was being interviewed. Half of the psychoanalysts were told that the man was a job applicant and the other half were told that he was a patient. Both groups of clinicians watched the same man exhibiting the same behaviour, those who were told that he was a patient rated him as being more disturbed, that is, less well adjusted. * It is easy to lapse into the mistaken belief that, somehow or other, labelling disorders explains why people are like they are. * Diagnosing a psychological disorder only describes the symptoms, it does not explain the origins of the disorder. * Ben-Zeev et al (2010) describes three types of stigma: public stigma whereby large groups of people hold stereotypical perceptions of a group and respond towards it negatively, self-stigma in which an individual loses their sense of self-esteem because they perceive that others view them negatively, and label avoidance where people avoid seeking out mental health services because they do not want to be labelled. * Labels can be quite dangerous triggers of negative stereotypes. * Knowing someone has a mental illness can lead to an increase in expressed prejudice towards them, (Crisp et al, 2000) as mental illness is often seen as unchangeable and fixed. * DSM has been criticized for attributing the cause of mental illness to the individual rather than to situations. * Mental health literacy has improved among the public, but attitudes towards people with depression and schizophrenia have not improved. People still prefer to maintain some distance between themselves and those with mental illness.

Answer 12

· Proper classification has advantages for a patient. · One advantage is that with few exceptions the recognition of a specific diagnostic category precedes the development of successful treatment for that disorder, · Treatments for diseases such as diabetes, syphilis, tetanus and malaria were found only after the disorders could be reliably diagnosed. · A patient may have a multitude of symptoms, but before the cause of the disorder and hence its treatment can be discovered, the primary symptoms must be identified. · Different kinds of mental disorder have different causes and they respond to different types of psychological treatment and drugs. If future research is to reveal more about causes and treatments of these disorders, we must be able to classify specific mental disorders reliably and accurately. · Another important reason for properly classifying mental disorders is prognosis. Some disorders have good prognoses; the patients are likely to improve soon and are unlikely to have a recurrence of their problems. · Other disorders have progressive courses; patients are less likely to recover from these disorders. · In the first case, patients can obtain reassurance about their futures; in the second case, patients' families can obtain assistance in making realistic plans.

Answer 13

Subjective distress: If people suﬀer or experience psychological pain we are inclined to consider this as indicative of abnormality. Maladaptiveness: Maladaptive behavior is often an indicator of abnormality. Statistical deviancy: The word abnormal literally means “away from the normal.” But simply consider- ing statistically rare behavior to be abnormal does not provide us with a solution to our problem of deﬁning abnormality. Genius is statistically rare, as is perfect pitch. However, we do not consider people with such uncommon talents to be abnormal in any way. Also, just because something is statistically common doesn’t make it normal. Violation of the standards of society: All cultures have rules. Some of these are formalized as laws. Others form the norms and moralstandardsthat we are taught to follow. Although many social rules are arbitrary to some extent, when people fail to follow the conven- tional social and moral rules of their cultural group, we may consider their behavior abnormal. Social discomfort: Not all rules are explicit.And not all rules bother us when they are violated. Nonetheless, when someone violates an implicit or unwritten social rule, those around him or her may experience a sense of discomfort or unease. Imagine Irrationalityand unpredictability:Aswe have already noted, we expect people to behave in certain ways. Al- though a little unconventionality may add some spice to life, there is a point at which we are likely to con- sider a given unorthodox behavior abnormal. If a per- son sitting next to you suddenly began to scream and yell obscenities at nothing, you would probably regard that behavior as abnormal. It would be unpredictable, and it would make no sense to you. Dangerousness: It seems quite reasonable to think that someone who is a danger to him- or herself or to another person must be psychologically abnormal.

Answer 14

In the United States, the accepted standard for deﬁning various types of mental disorders is the American Psychi- atric Association’s Diagnostic and Statistical Manual of Men- tal Disorders. This manual, commonly referred to as the DSM, is revised and updated from time to time. The cur- rent version, called DSM-5, was published in 2013. It is 947 pages long and contains a total of 541 diagnostic categories (Blashﬁeld et al., 2014). This recent revision of the DSM has been the topic of much debate and controversy. In the Thinking Critically about DSM-5 box we explain more about the DSM and discuss why a revision was necessary. Although the DSM is widely used, it is not the only psy- chiatric classiﬁcation system. The World Health Organiza- tion (WHO) produces a document with the rather macabre title of the International Classiﬁcation ofDiseases.The 11th revi- sion of this (called ICD-11) has just been published. Chapter V of this document covers mental and behavioral disorders (WHO, 2018). Although the ICD-11 has much in common with DSM-5, it also has many diﬀerences, with similar disor- ders having diﬀerent names, for example. The ICD-11 is used in many countries outside the United States. ICD code numbers (which are provided next to the various diagnoses in the DSM) are also used in hospital settings in the United States because the U.S. is a member country of the WHO. Within DSM-5, a mental disorder is deﬁned as a syn- drome that is present in an individual and that involves clin- icallysigniﬁcantdisturbancein behavior,emotion regulation, or cognitive functioning. These disturbances are thought to reﬂect a dysfunction in biological, psychological, or develop- mental processes that are necessary for mental functioning. DSM-5 also recognizes that mental disorders are usually associated with signiﬁcant distress or disability in key areas of functioning such as social, occupational, or other activi- ties. Predictable or culturally approved responses to com- mon stressors or losses (such as death of a loved one) are excluded. It is also important that this dysfunctional pattern of behavior not stem from social deviance or conﬂicts that the person has with society as a whole. The DSM-5 deﬁnition of mental illness was based on input from various DSM-5 work groups as well as other sources (Broome & Bortolotti, 2010; First & Wakeﬁeld, 2010; Stein et al., 2010). Although this deﬁnition will still not sat- isfy everyone, it brings us even closer to a good working description.

Answer 15

If deﬁning abnormality is so contentious and so diﬃcult, why do we try to do it? One simple reason is that most sci- ences rely on classiﬁcation (e.g., the periodic table in chem- istry and the classification of living organisms into kingdoms, phyla, classes, and so on in biology). At the most fundamental level, classiﬁcation systems provide us with a nomenclature (a naming system). This gives clinicians and researchers both a common language and shorthand terms for complex clinical conditions. Without having a common set of terms to describe speciﬁc clinical conditions, clinicians would have to talk at length about each patient individu- ally to provide an overview of the patient’s problems. But if there is a shared understanding of what the term “schizo- phrenia” means, for example, communication across pro- fessional boundaries is simpliﬁed and facilitated. Another advantage of classiﬁcation systems is that they enable us to structure information in a more helpful manner. Classiﬁcation systems shape the way information is organized. For example, most classiﬁcation systems typi- cally place diagnoses that are thought to be related in some way close together. In DSM-5, the section on anxiety disor- ders includes disorders (such as panic disorder, speciﬁc phobia, and agoraphobia) that share the common features of fear and anxiety. Organizing information within a classiﬁcation system also allows us to study the diﬀerentdisorders that weclassify andthereforetolearn new things. Inotherwords, classiﬁcation facilitates research, which gives usmore information andfacili- tates greater understanding, not only about what causes various disorders but also how they might best be treated. For example, thinking back to the cases you read about, Jessica has alcohol and smoking disorders, and Bryan has anorexia, depression, and a mood disorder. Knowing what disorder each of them has is clearly very helpful, because Bryan’s treatment would be very diﬀerent from Jessica’s. A ﬁnal eﬀect of classiﬁcation system usage is somewhat more mundane. As others have pointed out, the classiﬁca- tion of mental disorders has social and political implications (see Keeley et al., 2015; Kirk & Kutchins, 1992). Simply put, deﬁning the domain of what is considered to be pathological establishes the range of problems that the mental health pro- fession can address.Asa consequence, ona purelypragmatic level, it furthermore delineates which types of psychological diﬃculties warrant insurance reimbursement and the extent of such reimbursement.

Answer 16

Of course, a number of potential disadvantages are associ- ated with the use of a discrete classiﬁcation system. Classiﬁ- cation,byitsverynature,providesinformationin ashorthand form. However, using any form of shorthandinevitably leads to a loss of information. If we knowthe speciﬁc history, person- ality traits, idiosyncrasies, and familial relations of a person with a particular type of disorder (e.g., from reading a case summary),we naturally have much more information thanif we were simply told the individual’s diagnosis (e.g., schizo- phrenia). In other words, as we simplify through classiﬁca- tion, we inevitably lose an array of personal details about the actual person who has the disorder. Moreover, although things are improving, there can still be some stigma (disgrace) associated with having a psychi- atric diagnosis. Stigma, of course, is hardly the fault of the diagnostic system itself. But even today, people are gener- ally far more comfortable disclosing that they have a physi- cal illness such as diabetes than they are admitting to any mental disorder. This is in part due to the fear (real or imag- ined) that speaking candidly about having a psychological disorder will result in unwanted social or occupational con- sequences or frank discrimination. Be honest. Have you ever described someone as “nuts,” “crazy,” or “a psycho”? Now think of the hurt that people with mental disorders experience whenthey hear such words. In one study, 96 per- cent of patients with schizophrenia reported that stigma was a routine part of their lives (Jenkins & Carpenter-Song, 2008). Inspite of the large amount of information that is now available about mental health issues, the level of knowledge about mental illness (sometimes referred to as mental health literacy) is often very poor (Thornicroft et al., 2007). Stigma is a deterrent to seeking treatment for mental health problems. This is especially true for younger people, for men, and for ethnic minorities (Clement et al., 2015). Stigma is also a disproportionately greater deterrent to treatment seeking for two other groups: military personnel and (ironically) mental health professionals. Would you have predicted this? Why do you think this is the case? Related to stigma is the problem of stereotyping. Ste- reotypes are automatic beliefs concerning other people that we unavoidably learn as a result of growing up in a par- ticular culture (e.g., people who wear glasses are more intelligent; New Yorkers are rude). Because we may have heard about certain behaviors that can accompany mental disorders, we may automatically and incorrectly infer that these behaviors will also be present in any person we meet who has a psychiatric diagnosis. Negative stereotypes about psychiatric patients are also perpetuated in movies. If you have ever seen a horror movie you know that a com- mon dominant theme involves the homicidal maniac. And an analysis of 55 horror ﬁlms made between 2000 and 2012 has shown that it is people with psychosis who are most often portrayed as murderers (Goodwin, 2014). Stereotyp- ing is also reﬂected in the comment “People like you don’t go back to work” in the case example of James McNulty. Finally, stigma can be perpetuated by the problem of labeling. A person’s self-concept may be directly aﬀected by being given a diagnosis of schizophrenia, depression, or some other form of mental illness. How might you react if you were told something like this? Furthermore, once a group of symptoms is given a name and identiﬁed by means of a diagnosis, this diagnostic label can be hard to shake even if the person later makes a full recovery. It is important to keep in mind, however, that diagnos- tic classiﬁcation systems do not classify people. Rather, they classify the disorders that people have.And stigma may be less a consequence of the diagnostic label than a result of the disturbed behavior that got the person the diagnosis in the ﬁrst place. In some situations, a diagnosis may even reduce stigma because it provides at least a partial explanation for a person’s otherwise inexplicable behavior (Ruscio, 2004). Nonetheless, when we note that someone has an illness, we should take care not to deﬁne him or her by that illness. Respectful and appropriate language should instead be used. At one time, it was quite common for mental health professionals to describe a given patient as “a schizo- phrenic” or “a manic-depressive.” Now, however, it is widely acknowledged that it is more accurate (not to men- tion more considerate) to use what is called person-ﬁrst language and say “a person with schizophrenia,” or “a person with bipolar disorder.” Simply put, the person is not the diagnosis.

Answer 17

Negative reactions to people with mental illness are com- mon and may be a fairly widespread phenomenon throughout the world. Using focus groups, Arthur and colleagues (2010) asked community residents in Jamaica about the concept of stigma. Some participants came from rural communities, others from more urban areas. Regardless of their gender, level of education, or where they lived, most participants described highly prejudicial attitudes toward those with mental illnesses. One mid- dle-class male participant said, “We treat them as in a sense second class citizens, we stay far away from them, ostracize them, we just treat them bad” (see Arthur et al., 2010, p. 263). Fear of people who are mentally ill was also commonly expressed. A rural-dwelling middle-class man described a specific situation in the following way: “There is a mad lady on the road named […]. Even the police are afraid of her because she throws stones at them. She is very, very terrible” (p. 261). Moreover, even when more kindly attitudes were expressed, fear was still a common response. One person put it simply: “You are fearful even though you may be sympathetic” (p. 262). In short, the results of this study suggest that stereotyping, labeling, and stigma toward people with mental illness are not restricted to industrialized countries. Although we might wish that it were otherwise, prejudicial atti- tudes are common. This highlights the need for anti- stigma campaigns. For a long time, it was thought that educating people that mental illnesses were “real” brain disorders might be the solution. Sadly, however, this does not seem to be the case. Although there have been impressive increases in the proportion of people who now understand that mental disorders have neurobiological causes, this increased awareness has not resulted in decreases in stigma. In one study, Pescosolido and colleagues (2010) asked people in the community to read a vignette (brief description) about a person who showed symptoms of mental illness. Some people read a vignette about a per- son who had schizophrenia. Others read a vignette about someone with clinical depression or alcohol dependence. Importantly, no diagnostic labels were used to describe these people. The vignettes simply provided descriptive information. Nonetheless, the majority of the people who were surveyed in this study expressed an unwill- ingness to work with the person described in the vignette. They also did not want to have to socialize with them and did not want them to marry into their family. More- over, the level of rejection that was shown was just as high as it was in a similar survey that was done 10 years earlier. Over that same 10-year period, however, many more people embraced a neurobiological understanding about the causes of mental illness. So what this study tells us is that just because people understand that men- tal illness is caused by problems in the brain doesn’t mean that they are any less prejudiced toward those with mental illness. This is a disappointing conclusion for everyone who hoped that more scientiﬁc research into the biology of mental illness would lead to the elimina- tion of stigma. Stigma does seem to be reduced by having more con- tact with people in the stigmatized group (Corrigan et al., 2014; Couture & Penn, 2003). However, there may be bar- riers to this. Simply imagining interacting with a person who has a mental disorder can lead to distress and also to unpleasant physical reactions. In an interesting study, Graves and colleagues (2005) asked college students enrolled in a psychology course to imagine interacting with a person whose image was shown to them on a slide. As the slide was being presented, subjects were given some scripted biographical information that described the person. In some scripts, the target person was described as having been diagnosed with schizophrenia, although it was also mentioned that he or she was “doing much better now.” In other trials, the biographical description made no mention of any mental illness when the person on the slide was being described. Students who took part in the study reported more distress and had more muscle tension in their brows when they imag- ined interacting with a person with schizophrenia than when they imagined interacting with a person who did not have schizophrenia. Heart rate changes also sug- gested they were experiencing the imagined interactions with the patients as being more unpleasant than the inter- actions with the nonpatients. Finally, research partici- pants who had more psychophysiological reactivity to the slides of the patients reported higher levels of stigma toward these patients. These ﬁndings suggest that people may tend to avoid those with mental illness because the psychophysiological arousal these encounters create is experienced as unpleasant.

Answer 18

Just as we must consider changing societal values and expectations in deﬁning abnormality, so too must we consider diﬀerences across cultures. In fact, this is explic- itly acknowledged in the DSM-5 deﬁnition of disorder. Within a given culture, many shared beliefs and behav- iors exist that are widely accepted and that may consti- tute one or more customary practices. For instance, many people in Christian countries believe that the number 13 is unlucky. The origins of this may be linked to the Last Supper, at which 13 people were present. Many of us try to be especially cautious on Friday the 13th. Some hotels and apartment buildings avoid having a 13th ﬂoor alto- gether. Similarly, there is frequently no bed numbered 13 in hospital wards. The Japanese, in contrast, are not worried about the number 13. Rather, they attempt to avoid the number 4. This is because in Japanese the sound of the word for “four” is similar to the sound of the word for “death” (see Tseng, 2001, pp. 105–106). There is also considerable variation in the way diﬀer- ent cultures describe psychological distress. For example, there is no word for “depressed” in the languages of cer- tain Native Americans, Alaska Natives, and Southeast Asian cultures (Manson, 1995). Of course, this does not mean that members from such cultural groups do not experience clinically signiﬁcant depression. As the accom- panying case illustrates, however, the way some disorders present themselves may depend on culturally sanctioned ways of articulating distress. As is apparent in the case of JGH, culture can shape the clinical presentation of disorders like depression, which are present across cultures around the world (see Draguns & Tanaka-Matsumi, 2003). In China, for instance, individuals with depression frequently focus on physical concerns (fatigue, dizziness, headaches) rather than verbalizing their feelings of melancholy or hopelessness (Kleinman, 1986; Parker et al., 2001). This focus on physical pain rather than emotional pain is also noteworthy in Mr. GH’s case. Despite progressively increasing cultural awareness, we still know relatively little concerning cultural interpre- tation and expression of abnormal psychology (Arrindell, 2003). The vast majority of the psychiatric literature origi- nates from Euro-American countries—that is, Western Europe, North America, andAustralia/New Zealand (Patel & Kim, 2007; Patel & Sumathipala, 2001). To exacerbate this underrepresentation,research published in languages other than English tends to be disregarded (Draguns, 2001). As noted, prejudice toward people with mental illness seems to be found worldwide. However, some types of psychopathology appear to be highly culture speciﬁc: They are found only in certain areas of the world and seem to be highly linked to culturally bound concerns. A case in point is taijin kyofusho. This syndrome, which is an anxiety disor- der, is quite prevalent in Japan. It involves a marked fear that one’s body, body parts, or body functions may oﬀend, embarrass, or otherwise make others feel uncomfortable. Often, people with this disorder are afraid of blushing or upsetting others by their gaze, facial expression, or body odor (Levine & Gaw, 1995). Another culturally rooted expression of distress, found in people of Latino descent, especially those from the Caribbean, is ataque de nervios or an “attack of nerves” (Lizardi et al., 2009; Lopez & Guarnaccia, 2005). This is a clinical syndrome that does not seem to correspond to any speciﬁc diagnosis within the DSM. The symptoms of an ataque de nervios, which is often triggered by a stressful event such as divorce or bereavement, include crying, trembling, and uncontrollable screaming. There is also a sense of being out of control. Sometimes the person may become physically or verbally aggressive. Alternately, the person may faint or experience a seizure-like ﬁt. Once the ataque is over, the person may promptly resume his or her normal manner, with little or no memory of the incident. As previously mentioned, abnormal behavior is behavior that deviates from the norms of the society in which the person lives. Experiences such as hearing the voice of a dead relative might be regarded as normative in one culture (e.g., in many Native American tribes) yet abnormal in another cultural milieu. Nonetheless, certain unconventional actions and behaviors are almost univer- sally considered to be the product of mental disorder. Many years ago,the anthropologist JaneMurphy (1976) studied abnormal behavior in the Yoruba of Africa and the Yupik-speaking Eskimos living on an island in the Bering Sea. Both societies had words that were used to denote abnormality or “craziness.” In addition, the clusters of behaviors that were considered to reﬂect abnormality in these cultures were behaviors that most of us would also regard as abnormal. These included hearing voices, laugh- ing at nothing, defecating in public, drinking urine, and believing things that no one elsebelieves. Why do you think these behaviors are universally considered to be abnormal?

lecture 1 - what is normal? Flashcards

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