Week 3-Classification, Diagnosis and Formulation Flashcards
(40 cards)
What are the purpose and functions of Classification Systems?
-Research basis
-To suggest “correct” treatment
-To predict clinical outcomes
-To indicate probable cause of condition using research
-To enable clinical communications for referrals, recommendations and treatment
-Understanding of experiences
-Access to support
Name the 2 main Diagnostic manuals
1.World Health Organisation’s International Classification of Disease (ICD) (popular in European countries, Basis of NHS diagnosis, Latest is ICD-11 (WHO, 2022))
2.American Psychiatric Association’s Diagnostic and Statistics Manual (DSM) (popular in the US, recommended for research classification - standard in Europe, Latest is DSM-5-TR (APA, 2022))
True or false: Autism and ADHD are mental disorders
False! they last a lifetime yet are treated like mental disorders
Define Autism
A developmental neurocognitive difference resulting in divergent perception of the world, particularly in relation to sensory and social experiences.
Define ADHD
A developmental neurocognitive difference. Associated with interest-driven rather than importance-driven attention, executive functioning difficulties and differences in memory.
Define Pathological Demand Avoidance (PDA)
Often a co-morbid diagnosis is given to people diagnosed as autistic who experience anxiety in response to demands. People with PDA report that demands create anxiety and result in avoidance even if they are essential to participating in a desired activity.
Why is recognition via classification essential for many neurodivergent people?
Because late diagnosis can result in:
-Lack of access to essential support
-Increased masking (Bargiela et al., 2016)
-Delayed self-acceptance and increased self-criticism (Leedham et al., 2019)
-Mental health and wellbeing consequences
-However, diagnosis too early in life can lead to enrollment in ‘curative’ interventions that can cause trauma
Give a brief history of classification
1896:Kraepelin attempted to classify conditions of mental health into 2 broad categories 1.Dementia precox (now schizophrenia) 2.Manic Depression
1908:Bleuler extended Kraepelin to include the group of schizophrenias which encompassed dementia precox and included “autism” as a symptom
1943:Kanner publishes a paper on “autism” as it is known today. Followed shortly in 1944 by Asperger. Kanner’s “classic autism” and “Asperger’s syndrome” were both added as subtypes of a new syndrome later on
Present:Categories and subcategories change with each new edition of the classification systems
How were categories constructed?
-DSM-5 included over 500 clinicians, 13 work groups and 13 major conferences and hundreds of peer-reviewed papers from over the last decade
-Social influence is possible (as removal of homosexuality)
-DSM-5 workgroup negotiation with ASAN
-Culture and political movements both influence categories which change over time (meaning future disorders or disabilities could be removed in the future)
What was the DSM-5 workgroup negotiation with ASAN?
-ASAN lobbied with the relevant workgroup to try and overturn a decision to include an autism severity scale in DSM-5 (Kapp & Ne’eman, 2020)
-The potential was to overcome the problematic severity assumptions which creates stigma (i.e., how do we know what’s severe?)
-DSM-5 employed a criteria that dichotomised autism into types 1-3 (APA, 2013-based off support needs) due to a DSM-wide decision from APA that all conditions now have severity scales
What are causal models?
-Classification takes a BMM position towards mental health conditions
-Mirrors physical healthcare, applying diagnoses based on symptoms (Kinderman, 2014) but is less objective (Johnstone, 2013)
-Psychiatry is treated as a branch of medicine using medical language
-Without biological markers, we can only rely on behaviour as an indicator of cognitive differences or ‘deficits’ (Waltz, 2013)
-Mental health is dynamic and changes over time so hard to diagnose objectively
What is the impact of causal models on research and practise?
-Research and practise are predominantly influenced by the BMM and the diagnostic classification systems in place (Johnstone, 2013)
-Like physical health, categories are used to develop interventions
-A cure and prevention model results, which treats human differences as a deficit to be corrected. This is particularly problematic for neurodivergent categories (Waltz, 2013)
What are the classification issues in the BMM?
-It pathologises human experience, following the idea that our mental health struggles and/or neurodivergent differences indicate something is ‘wrong’ with us
-For neurodivergent conditions such as ADHD or autism, your experiences have to have a negative impact on your life to justify diagnosis (Pearson and Rose, 2021)
-Overlooks meaning behind behaviour, traits or symptoms e.g., PTSD and PDA
-“Instead of seeing people’s difficulties as understandable and natural responses to the terrible things that have happened to them, the person is seen as having something wrong with them – an ‘illness’.” (Kinderman, 2014) (more an example summarising what was said above)
What is meant by construct validity?
-Validity in this context means to be scientifically meaningful and represent ‘real’ things
-Mental health struggles have been recorded throughout human history: Socrates (469-399 BC) - auditory hallucinations and catatonia (awake but not responsive to people and environment)
-“another deceased twentieth-century female writer, whose family had been greatly upset by suggestions that she might have been autistic.’” (Example by Limburg, 2021).
How does psychology pathologise experiences?
-Psychology typically views mental illness as experiences and related struggles which are understandable within the context of a person’s life (Johnstone, 2013)
-Singer 1998:Neurodiversity from biodiversity - all human brains differ, divergent groups represent natural species variation
-Classification and pathologisation reduce human experiences and differences to deficits (Kinderman et al., 2013)
-We try to look at what’s happened to people and lead it back to certain traits
What is meant by predictive validity?
If a mental health condition were a valid medical category, we should be able to reliably predict outcomes and effective treatments (Johnstone, 2013)
-Diagnosis does not predict outcomes or the course of a condition. It also does not predict medication response (Kendell, 1988)
-This is not to say that medication is not useful or that is should not be offered. But it does suggest that positive effects are non-specific and unpredictable.
What is meant by Inter-rater reliability?
-Diagnosis is seen as reliable if 2 people agree on which category best applies and if the same decision would be reached if the person was reassessed (Johnstone, 2013).
-Early research showed clinician disagreement about psychiatric diagnosis and that diagnostic practises differ between countries (Beck et al., 1962; Blashfield 1973)
-Misdiagnosis is still common and people often acquire multiple diagnoses: 50% of people with 1 diagnosis in the USA national co-morbidity study had at least one more, 25% had more than 3 (Kessler et al., 2005).
-Lots of overlap between psychosis and personality disorder approach (so clinicians could give different diagnosis)
-The assumption that diagnosis is objective which isn’t true
-Autism and ADHD was avoided diagnosing because they thought it would make it unreliable
What are the 5 sources of error which can cause unreliable diagnoses according to Kreitman (1961)?
- Raters might differ e.g., psychiatrists
- Examination might differ each time
- Patients might differ e.g., mention different things
- The method of analysis might differ (e.g., different ways of combining symptoms)
- Could be different systems of names and styles of reporting
What’s subjectivity in relation to classification?
-Criteria are based on subjective norms, which leads to low reliability. There is nothing inherently wrong with subjectivity in clinical judgement, the issue is with presenting it as objectivity asif we could obtain everything a person has gone through (Johnstone, 2013).
-Prolonged grief disorder: How much grief is too much grief?
-“I sought your warm ankle between the cold sheets,
Daring to stretch to the foot of the bed. You were nowhere you should be, it filled me with dread.”
Harrison, 2022 (Just an example)
What is the impact of racial and cultural bias in classification?
-Black people in the UK are more likely to be diagnosed as having mental illnesses and to be detained in secure hospitals (Commander et al., 1997) than Asian and White people.
-People from ethnic minority groups tend to receive more medical and physical treatments, and are under-represented in less medical forms of treatment, such as counselling and psychotherapy services (Ahmed, 1995; Littlewood and Lipsedge, 1997)
How does Diversity impact Classification?
-People who see their experiences as spiritual (e.g., auditory hallucinations or visions) are overlooked and pathologised (Jackson & Fulford, 1997)
-Diagnostic systems risk pathologising behaviours that aren’t considered normal in white, western, male, middle-class culture (Cochrane & Sashidharan, 1995)
-Autistic people make up a large portion of in-patients detained under the mental health act and have an average stay of 5 years (NAS, 2023)
How does Heterogeneity impact Classification?
-People with the same diagnosis lack the same experience (Johnstone, 2013)
-Heterogeneity does not challenge that a phenomena exists, but calls for an acknowledgement of cultural influence and to move away from assumptions that clinical conditions are objective and waiting to be discovered (Botha, 2021)
“I wouldn’t want to mislead you into thinking that there is any general agreement as to what autism is – there really, really isn’t.” (Limburg, 2021) (example)
-Understandings need to move away from an assumption of a set group of traits.
How does Reliability impact Classification?
-Increasing the amount of diagnostic labels and subtypes is seen as a method to improve diagnostic precision and increase reliability (Johnstone, 2013)
-Ignores that new criteria remains subjective and culturally influenced.
-Calls for more homogenous subgroups of autism in light of high heterogeneity (Happé et al., 2006; Frith, 2021)
-Beyond specifying whether intellectual disability and language impairments are present, subtypes have historically been unsuccessful (Fletcher-Watson & Happé, 2019).
Why is Stigma an issue around Diagnosis?
-Stigma arises from categorising people based on what is ordinary or typical within a social context (Goffman, 1963).
-This leads to ‘us and them’ thinking, creating stigma which can be felt and internalised by the person being ‘othered’ (Pearson & Rose, 2021)
-Link & Phelan (2001) said there are 3 main types of stigma:
1. Structural
2. Interactional
3. Personal Response