Lecture 9 - Critical issues in clinical diagnosis Flashcards
(28 cards)
Why is it difficult to divide mental health conditions up using principle of divisible categories?
Overlap between them - comorbidity
Not discrete categories or dimensions
Why is it important to critique diagnoses?
- It is clearly fallible – history tells us this
- It is clearly a product of social, cultural, and structural phenomena, of which all humans are a part
- It is clearly our role as scientific psychologists to regard diagnostic ‘entities’ critically, considering the evidence that supports their use
On what three bases can we critique classification/diagnosis?
- Validity - does it do what it says it is meant to do?
- How can it be improved? e.g. subtypes or merge with another diagnosis
- Do we need it at all? e.g. does it actually lead to help and treatment that is applicable?
What is the main benefit of diagnostic categories?
Targeted, specific, personalised
Can give someone treatment based on their symptoms
Symptoms are explainable
What should diagnostic categories do?
Identify symptoms or behaviours
OR
Identify properties beyond symptoms or behaviours, in those who have the diagnosis that can distinguish them from those who don’t.”
e.g. measurable biomarkers:
- Genetic
- Functional connectivity
- Structural connectivity
A DSM 5 diagnostic category with biomarkers:
Wernicke-Korsakoff syndrome - what are symptoms?
Prolonged decline from previous levels of cognitive functioning (especially executive function), functional impairment, not explained by other causes.
A DSM 5 diagnostic category with biomarkers:
Wernicke-Korsakoff syndrome - what is the biological cause of symptoms?
Thiamine deficiency
Common reasons for thiamine deficiency include alcohol use disorders and conditions resulting in malnutrition.
How can you test to see if diagnoses are reliably given, or if different diagnostic categories are assigned to the same set of symptoms?
Assess validity and reliability
- Assess with test-retest reliability - Validity = meaning behind it
Do MDD and GAD have good diagnostic agreement? (kappa)
No - 0.28 and 0.2
Despite being very common conditions
What conditions have good diagnostic agreement between clinicians (kappa)?
Major neurocognitive disorder - 0.78
PTSD - 0.67
Bipolar disorders and psychoses - good agreement
Does reliability between clinicians mean there is high validity for that diagnosis?
No
- The mere agreement between diagnosticians is no guarantee that diagnoses correspond to meaningful clusters of symptoms, with distinct pathophysiology and aetiology, which predict the effectiveness of particular treatments - Reliability is necessary but not sufficient for validity
What is Richard Bentall’s criticism of diagnostic categories?
Psychiatric diagnoses are poor predictors of response to treatment, not indicating which patients will respond to which drugs or therapies.
They are therefore hardly more meaningful than star signs
He believes in symptoms-driven treatment, not diagnosis driven treatment
What is an issue with categories instead of dimensions in the DSM?
no clear line between:
‘having’ a disorder vs not having one
having one disorder vs having another
What did Kraeplin propose that each category of diagnosed disorder should have?
A specific biological pathology that accounts for it & specific therapy to treat it - clearly not the case in the DSM 5
What are we at risk of doing with an ever-expanding number of diagnoses?
are we ‘pathologising’ normal human experiences?
e.g. pathological grieving disorder
How do different voice-hearing experiences critique distinct categories for disorders?
- Some people have positive experiences of voice-hearing
- Language between having and not having disorder can be unclear
Why does diagnostic shift present an issue for diagnostic categories?
Some diagnoses not stable over time - undermines validity
Are people actually changing categories or are the categories just not matching the experience?
Some distinctions between categories of disorder do not reflect patterns of clinical risk in real life situations - how is this shown in anorexia?
- Previously thought lower BMI = more physical risk
- ACTUAL Biggest risk to body = rapid weight loss regardless of BMI
- Some people may not get treatments they need as they are not at a low BMI despite being at severe physical risk
What is the issue with under or over pathologising grief?
Recent bereavement = no depression diagnosis - issue because someone could have had depression before and then reached out for help after bereavement
However, if grief is no longer an ‘exclusion’ in depressive disorder diagnosis, do we risk pathologizing normal experiences?
What are the six main arguments against diagnostic categories based on validity?
- Lack of biological markers for separate disorders
- People often get more than one diagnosis, and often ‘shift’ categories over time
- Diagnoses imply external, fixed phenomena (called reification) – inherently excludes experiences that don’t fit into those boxes
- People can have ‘sub-threshold’ problems but experience more impairment than those who meet the full set of criteria
- Where there are clear genetic (and psychosocial) risk factors, these frequently cross over diagnostic categories
- Symptoms are often continuous with ‘typical’ experiences: dimensional
What does it mean that diagnoses have utility?
They convey information about presenting symptoms, outcome etc.
Are they actually useful - do they help people that receive them?
Why are diagnostic categories important?
- Fundamental part of clinician-patient communication, evidence evaluation and decision-making - understanding mental health better
- Helps identify useful / unhelpful / possibly dangerous interventions e.g. SSRIs for bipolar
- Clinician can use it to validate the patient’s experiences
- Requires honesty but pragmatism on the part of the clinician
- Minimise disadvantages and maximise advantages
- Use alongside a detailed formulation of the patient’s difficulties
In a thematic analysis of service user (SU) and clinician experiences of diagnosis, what was thought about the process of deciding on a diagnosis?
- SUs found diagnostic process more validating & effective when it was holistic, thorough, & considered symptom burden & chronicity.
- Diagnostic manuals could be helpful but sometimes symptom descriptors felt inaccurate or incomplete.
- Tensions between clinician wanting to be sure of diagnosis vs. SU experience of perceived delays in the process. Reduced person’s trust in the clinician
- Where diagnosis was felt to be inaccurate, caused distress & loss of trust.
In a thematic analysis of service user (SU) and clinician experiences of diagnosis, what was thought about communicating and understanding the diagnosis?
- Clinicians torn between SU’s right to know & worries about diagnosis doing harm
- SUs overall preferred disclosure: relief, empowerment, validation, self-understanding
- Having a diagnosis (or change to it) withheld caused isolation & confusion - damaged therapeutic relationship
- Paradox: clinicians worry about stigma & therapeutic relationship damage, but non-disclosure more likely to cause these issues than disclosure.
- SUs reported not receiving enough time or information to understand the diagnosis
- SUs felt that aetiology often went unexplored and diagnoses therefore felt ‘without basis’ -> more likely to reject diagnosis
- Thinking condition was permanent or untreatable was particularly damaging
- Some found biomedical explanations helpful (reduced self-blame) but others felt it was inconsistent with their prior lived experiences of psychosocial causes
Had a label for what problem was - underlying experience was ignored
