1. CLASSIFICATION AND DIAGNOSIS CHRISTMAS CAROLS Do you hear what I hear? (schizophrenia) Hark! The herald angels sing about me! (narcissism) Jingle bells, jingle bells, jingle bells, jingle bells, jingle bells, jingle bells, jingle bells, jingle bells (obsessive- compulsive disorder) Deck the halls and walls and house and street and stores and... (mania) Santa Claus is coming to get me (paranoia)

2. CLASSIFICATION AND DIAGNOSIS LECTURE OUTLINE Background on classification DSM-IV Reliability and validity Problems and objections to classification Epidemiological findings re: the different disorders

3. CLASSIFICATION AND DIAGNOSIS Background – Some key terms Classification Diagnosis and diagnostic system Assessment Sign vs. symptom Comorbidity

4. CLASSIFICATION AND DIAGNOSIS Background – Functions of a good classification system Organization of clinical information Prognosis/prediction Treatment possibilities/recommendations Heuristic Guidelines for financial support

5. CLASSIFICATION AND DIAGNOSIS Background – History Greeks – melancholia, senility, alcoholism Kraeplin (1896) – first psychiatric classification system DSM I (1952) & DSM II (1968) – very brief manuals, guided by psychoanalysis, gross categories (e.g., neurosis, psychosis), lack of reliability, no research base

6. CLASSIFICATION AND DIAGNOSIS Background – History DSM III (1980), DSM IV (1994), DSM IV TR (2000) – field trials to improve reliability, better research base, multiaxial classification

7. CLASSIFICATION AND DIAGNOSIS Background – The perfect system would: classify disorder by presenting signs and symptoms, etiology or history, prognosis, response to treatment identify different symptom clusters that accurately signal different disorders with no overlap between symptoms or signs between disorders identity precise effective treatments

8. CLASSIFICATION AND DIAGNOSIS – DSM IV

9. CLASSIFICATION AND DIAGNOSIS – DSM IV

10. CLASSIFICATION AND DIAGNOSIS Reliability and validity reliability – consistency or repeatability of diagnoses inter-rater reliability – extent to which 2 clinicians agree on the diagnosis of a client study by Beck et al. (1962) – reliability for DSM I categories ranged from 38% to 63%

11. CLASSIFICATION AND DIAGNOSIS Reliability and validity study by Ward et al. (1962) of the same data – found that most of the error in diagnosis had to do with inconsistencies on part of clinicians (33%) or inadequacies of the diagnostic categories (63%), little error attributed to inconsistencies in info presented by clients

12. CLASSIFICATION AND DIAGNOSIS Reliability and validity Spitzer & Fleiss (1974) – review of the literature of reliability of DSM II – only 3 categories (mental retardation, alcoholism, organic brain syndrome) had adequate reliability

13. CLASSIFICATION AND DIAGNOSIS Reliability and validity Research undertaken to improve reliability of subsequent DSM versions Main finding is that reliabilities for broad categories of Axis I is adequate, but poor for sub-categories

14. CLASSIFICATION AND DIAGNOSIS Reliability and validity Validity – reliability is a prerequisite for validity Concurrent validity – extent to which diagnostic category is related to non- symptom attributes (e.g., delusions should be related to poor occupational functioning)

15. CLASSIFICATION AND DIAGNOSIS Reliability and validity Predictive validity – extent to which diagnostic category can predict future functioning (e.g., does conduct disorder in childhood predict antisocial behavior in adult life)

16. CLASSIFICATION AND DIAGNOSIS Problems of DSM Discrete categories vs. continuum – where to do draw the line Gender bias – Phyllis Chesler (1972) – women are diagnosed for overconforming to and underconforming to sex role stereotypes

17. CLASSIFICATION AND DIAGNOSIS Problems of DSM Gender bias – Broverman (1970) – study of therapists’ criteria for healthiness in women and men – healthy woman or unhealthy person, unhealthy woman or healthy woman Gender bias – Paula Caplan (1991) – SDPD and LLPDD

18. CLASSIFICATION AND DIAGNOSIS Problems of DSM Cultural bias – DSM constructed predominantly by white, US men Heterosexist bias – “homosexuality” was considered a DSM disorder until 1974; it was de-listed by a referendum of psychiatrists!

19. CLASSIFICATION AND DIAGNOSIS Broader objections to classification Adherence to medical model – do psychologists want to buy into that? Labeling Stigma and discrimination Abuse and iatrogenic illness

20. CLASSIFICATION AND DIAGNOSIS Epidemiological findings incidence prevalence Midtown Manhattan study (Srole et al., 1962) – in 1954 study, 23% of adults (20-59) had marked or severe mental illness 1974 follow-up of original sample, now aged 40-79, 18% marked or severe

21. CLASSIFICATION AND DIAGNOSIS Epidemiological findings Stirling County Nova Scotia study (Leighton et al., 1963) – 37% of sample of 273 people judged to have symptoms indicating mental disorder NIMH study in 3 US cities in early 1980s – 6-month prevalence rates of 12-13%

22. CLASSIFICATION AND DIAGNOSIS Epidemiological findings – Ontario Health Supplement study (1990s) 1-year prevalence rate for any disorder - 30% lifetime prevalence rate – 48% most common disorders – substance abuse, anxiety, mood disorders

23. CLASSIFICATION AND DIAGNOSIS Epidemiological findings – Ontario Health Supplement study (1990s) substance abuse more common among men; anxiety, mood disorders more common among women of those judged as having a disorder – 75% percent reported that they had NOT sought help for their problems – Why?

24. CLASSIFICATION AND DIAGNOSIS Epidemiological findings – Ontario Health Supplement study (1990s) 81% don’t believe they have a problem 57% embarrassed to ask for help 42% uncomfortable asking for help

25. CLASSIFICATION AND DIAGNOSIS Epidemiological findings – Ontario Health Supplement study (1990s) 42% of those who did seek help were judged not to have a mental health problem! What does this say about the way mental health services are organized?

26. SUMMARY OF CLASSIFICATION AND DIAGNOSIS DSM-IV is current diagnostic system; uses multi-axial classification and has improved reliability over previous versions a number of problems and objections to use of diagnostic systems remain epidemiological studies of disorders show that these problems are widespread; a major public health problem