Clinical Psychology
● Clinical psychology is about explaining and treating mental health issues and of the
different ways of treating them, including counselling and drug treatments.
Diagnosing mental disorders-
● When defining abnormality, psychologists can use the 4 D’s which includes deviance,
distress, dysfunction and danger.
● Davis (2009) views this technique as useful because using the 4 D’s can help
practitioners to see when a condition might need a DSM (Diagnostic and Statistical
Manual for Mental Disorders) diagnosis.
Deviance:
● Deviance refers to thoughts, emotions and behaviours that do not fit into the
accepted norms of society.
● Such social norms depend upon the historical context and the culture, age, and
gender of the individual and this is important when assessing deviance.
Distress:
● Distress is when someone with a disorder experiences negative feelings such as
being upset and/or anxious.
● It is thought that abnormality in terms of mental health is accompanied by negative
feelings for example with depression you tend to be anxious, so this means that
distress is a strong indicator to abnormalities/mental health issues.
● A clinician will consider the intensity or duration of distress by using quantitative self-
report measures such as the Kessler Psychological Distress Scale (K10) which
focuses on experiences in the past four weeks.
Dysfunction:
● Dysfunction is when a person’s behaviour is not successful in carrying out everyday
tasks and living their lives in general. Such behaviour includes the inability to get up in
the morning, inability to complete tasks at work or college and problems in participating
in routine activities i.e. gym or doing hobbies.
● Dysfunction is important in defining abnormality and diagnoses as dysfunction must
occur in more than one part of the person’s life (e.g. it can be in work life or social life)
for a diagnosis to be given.
● Psychologists use a variety of objective measures such as the WHODAS II
questionnaire which looks at factors such as a deterioration in self-care.
● However, dysfunctional behaviour can be deliberate and does not on its own signal
disorder.
Danger:
● Danger which refers to danger towards other people or to themselves. Danger
includes violent behaviour directed at others and also suicidal/self-harming thoughts.
● In the UK, if a person is perceived to be dangerous either in a public or private place,
they may be detained under the Mental Health Act. This requirements the agreement
of three professionals.
Evaluation of the 4 D’s
Strengths-
● Some diagnoses are clearly illustrated by deviant behaviour such as paedophilia
where the symptoms shown in the DSM clearly indicate deviance so in some cases
deviance is easily identifiable
● We may consider danger useful as having thoughts and behaviours the pose a threat
to yourself and others can be a sign of severe psychological problems which is
acknowledged by the UK’s NHS.
● The four D’s have practical applications because they are useful for professionals
when considering when a patient’s symptoms or issues become a clinical diagnosis.
, ● The four D’s support the validity of the DSM as a diagnostic classical system in that
various diagnoses are shown to focus on specific D’s, showing each has a value.
● Different combinations of the four D’s can lead to useful diagnosis thus this model is
flexible.
Weaknesses-
● Deviance can be difficult to use in diagnosis because different mental disorders can
show similar deviance, so it is hard to identify the specific mental disorder. Deviance
is that different societies have different views on what deviant behaviour is for
example a woman in western society shaving her hair may be considered deviant
whereas in remote parts of the globe such as the Amazon this may be considered a
‘norm’- subjectivity in diagnosis.
● There is subjectivity in the application of the four D’s for example, what a professional
may view as dysfunctional such as not going to work may not be considered
dysfunctional to the individual or other professionals – reliability.
● Distress is quite hard to measure as a person may be unable to function but does not
experience feelings of distress.
● Lack of objectivity – raises issues of reliability. If the four D’s are used by different
professionals, they may not come to the same conclusion.
● Davis (2009) discusses a 5th D, which is duration which refers to the length the
individual has had the symptoms. By adding a 5th D, the original four D’s are
insufficient in themselves which is a criticism.
● We end up with labels for people with mental health issues for example, ‘danger’ may
lead people to equate mental illnesses with being dangerous. This becomes distorted
in the media and popular films- ‘self-fulfilling’ prophecies?
Classification systems for mental health
DSM-V (Diagnostic and Statistical Manual of Mental Disorders)
● This is published by the American Psychiatric Association (APA) and provides a
criteria from which a mental disorder can be diagnosed.
● It contains a list of symptoms (a classification system) that can be matched to the
patient’s symptoms. The best match is the diagnosis.
● It was first used to identify disorders experienced by WW2 soldiers, and was first
published in 1952 but has been revised 6 times (recent version is DSM-5 published
in 2013).
The current version of DSM-V/5 is split up into 3 parts:
Section 1- Explains what the DSM is and some of the changes e.g. moving away from the
multiaxial system (as the DSM-IV did).
Section 2- This section gives actual diagnostic criteria and codes. For example, it covers
neurodevelopmental disorders (e.g. autism spectrum disorder), schizophrenia spectrum and
other psychotic disorders, bipolar and related disorders, depressive disorders and many
more.
Section 3- This is about the future of diagnoses and includes disorders which may need
further research before they are included in Section 2 for example, the preoccupation with
games.
,Evaluation of DSM5-
Strengths- Weaknesses-
It has stood the test of time- whilst it has its The BPS published a largely critical response- it
flaws it is better than anything currently argued that the diagnosis should fit the patient,
available. but the DSM-5 tries to make the patient fit the
diagnosis.
DSM-5 underwent field trials before publication, There was criticism that those reviewing the
which included test-retest reliability where DSM-5 had to sign an agreement that they would
different clinicians independently evaluated the not talk about the process of reviewing this
same patient. version of DSM- no transparency so cannot be
challenged. Perhaps a lack of credibility.
DSM-5 was greeted positively by the UK mental BPS has also said that the DSM-5 brought in
health charity Mind. social norms to be considered. Deviance and
dysfunction relate to culture.
Despite the concerns about over-medicalisation, The DSM-5 has been criticised for 'medicalising'
DSM-5 has fewer diagnostic categories than the normal behaviour and mood.
previous version.
Reliability- Validity-
☺ DSM-5 field trials demonstrated impressive ☹ DSM-5 has been criticised by psychiatrists and
levels of agreement between clinicians for a psychologists for merely naming and classifying a
variety of disorders. For example, Regier et al disorder rather than identifying the cause of the
(2013) reported that three disorders, including disorder. Perhaps without knowing the causes
PTSD, had kappa values ranging from 0.60- effective treatment may not be possible.
0.79 (very good) whilst seven more diagnosis,
including schizophrenia, had kappa values of
0.40 to 0.59 (good). Schizophrenia has a
kappa value of 0.46 which is ‘good’
☹ Mood disorders have poor reliability using the
DSM-5 as low as 0.28 (Regier et al), and thus
ICD-10 may be more preferable for these
disorders.
☹ However, what counts as an acceptable level ☺ The DSM was developed in the USA and is
of agreement has plummeted over the last 35 used widely in many other cultures which can
years. Cooper (2014) explains that DSM-5 suggest its validity. For example, the study Lee
task force classified levels as low as 0.2-0.4 2006 was conducted in Korea to see if the DSM
as ‘acceptable’. According to Cooper 2014 (though it was the DSM-IV-TR) was valid in a non-
schizophrenia had a reliability estimate of Western culture and it was found that it was valid
0.81 in the DSM-3 and just 0.46 in the DSM-5. (for ADHD).
So the DSM-5 may in fact be less reliable
than previous versions.
- But Kupfer and Kraemer (2012) explains that
clinicians part of the DSM-5 task force were
asked to ‘work as they usually would’ and to
, mirror normal practice whereas DSM-3 used
carefully screened ‘test’ clients and clinicians
were given detailed training. So perhaps the
DSM-5 is more suitable for real practice than
DSM-3.
It seems that there might be reliability in the DSM- ☹ However, some studies (Everad 2014) have
5 for some disorders, but not for others, as shown shown that culture can affect diagnosis. For
by the field trials. For example, autism spectrum example, symptoms that are seen in Western
and ADHD in children and PTSD and binge-eating countries as characterising schizophrenia (such as
disorders in adults had good or very good hearing voices) can be interpreted in other
reliability whereas major depressive disorders countries as showing possession by spirits, which
(0.28) and generalised anxiety disorder had rather is not considered negative at all. So depending on
low reliability scores. cultural expectations on what is being measured,
the DSM is not always valid.
ICD-10 (International Classification of Diseases)
● The ICD is concerned with all diseases; so both physical and mental diseases.
● The World Health Organisation (WHO) are heavily involved in the ICD . For example,
ICD-10 is used to monitor incidence (when a health problem occurs) and prevalence
(how frequently the health problem occurs) for WHO as well as mortality (number of
deaths) and morbidity rates (number of diseases).
● Chapter 5 is entitled Mental and Behavioural Disorders which each disorder has a
code starting with F. Each section has left over codes, allowing new disorders to be
added without having to recode other disorders.
● This multilingual, freely available resource provides a common language so that data
collected in different countries can be usefully compared.
Making a diagnosis using the ICD-10-
● The clinician selects keywords from an interview with a client that relate to their
symptoms- such as hallucinations, delusions, incoherent speech. The clinician can
then look up these symptoms in an alphabetical index or may go straight to an
obvious section such as schizophrenia. The clinician then uses other symptoms to
locate sub-category.
Improvements to the ICD-10-
● Culture bias in diagnosis means that clients in one culture could be given a different
diagnosis to clients in another culture, despite presenting very similar symptoms-
because of different language/culture norms. So as a result ICD-10 was available in
many different languages.
Evaluation of ICD-10-
Reliability: Validity:
☺ Research evidence by Ponizovsky et al ☺ Mason et al (1997) have shown that the
(2006) from a large-scale longitudinal study, diagnosis of schizophrenia using the ICD-10 has
found that PPV scores (the proportion of good predictive validity. The ICD-9 and ICD-10
people who retain the same diagnosis when were ‘reasonably good at predicting disability’ in
reassessed) increased by 26% for 99 people with schizophrenia 13 years later as
schizophrenia, 16% for mood disorders and assessed by a questionnaire.
8% for anxiety disorders- this shows
increased reliability from ICD-9 to ICD-10.
☹ Reliability for childhood disorders and
personality disorders were interpreted as low as
55% and 56% respectively.
☺ ICD-10 showed good consistency when two ☺ It can reliably diagnose schizophrenia. Only
