4.

Discuss validity and reliability of diagnosis

Diagnosis is based on the ABCS, as well as the classification systems such as the DSMIV and
the ICD. The reason for the lack of validity and reliability of diagnosis has to do with the lack of
scientific evidence in diagnoses, the cultural aspects that can contribute to the lack of reliability,
as well as the psychiatrist’s attitude and prejudices.
o For a classification system to be reliable, it should be possible for different clinicians,
using the same system, to arrive at the same diagnosis for the same individual
o For a classification system to be valid, it should be able to classify a real pattern of
symptoms which can then lead to an effective treatment
o The classification system is descriptive and does not identify any specific causes for
disorders  so its hard to make a valid diagnosis for psychiatric disorders because there
are no objective physical signs of such disorders
o Appropriate identification of diagnostic criteria is, to a large extent, influenced by
psychiatrists
Example: The Great Ormond diagnostic system for children (some psychiatrists
used this because they found it to be more reliable than the DSMIV and the ICD)
o Rosenhan (1973)
Aim: Test the reliability of psychiatric diagnoses
Method: Field experiment
Description: five men and three women who were normal went to 12 different
psychiatric hospitals to get admission by stating that they had been hearing
voices.  7 of them = diagnosed with schizophrenia and it took an average of 19
days before they were discharged and seven of them were labeled as
schizophrenic in remission. Also, Rosenhan wanted to see if abnormal patients
would be able to be classified as abnormal and out of 41 of these abnormal
patients, 19 were suspected to be frauds by some of the psychiatrists
Conclusion: Not possible to distinguish between sane and insane in psychiatric
hospitals and there’s a lack of scientific evidence on which medical diagnoses can
be made.
Strengths: Gives insight to the lack of reliability in psychiatric diagnoses
Limitations: Ethical issues such as deceit to the psychiatrists
o Beck et al (1962) found that the agreement for diagnosis on 153 patients between two
psychiatrists were only 54%
o Cooper et al (1972): NY psychiatrists were more likely to diagnose schizophrenia than
London psychiatrists  showing how culture affects the reliability of diagnosis
o Lipton and Simon (1985): Randomly selected 131 patients at a NY hospital and tested
them to arrive at a diagnosis. This diagnosis was then compared with the original
diagnosis. 89 originally diagnosed with schizophrenia, and only 16 received the same
diagnosis. 50 were diagnosed with mood disorder, and only 15 had originally been
diagnosed with mood disorders.  Lack of scientific evidence and the diagnoses may be
influenced by the attitudes and prejudices of the psychiatrist

5. Discuss cultural and ethical considerations in diagnosis.

Ethical Considerations:
 Labels
Szasz (1974) argued that people use labels such as mentally ill, criminal, or foreigner in
order to socially exclude people.
-People who are different are stigmatized
-The psychiatric diagnosis provides the patient with a new identity
(schizophrenic)  Szasz’s criticism was raised about the ethical implications in
diagnosis and now in the DSM-IV instead of referring to someone as a
schizophrenic, they are labeled as an individual with schizophrenia.
*Considerable ethical concern about labeling, which results from identifying
someone’s behavior as abnormal because this psychiatric diagnosis may be a label
for life, even if a patient no longer shows the symptoms, they will be labeled as
“disorder in remission”*
Scheff (1966) argued that one of the adverse effects of labels is the self-bullying
prophecy – people may begin to act as they are expected to. (therefore internalizing the
role that they are labeled as which can lead to an increase in the symptoms.
Doherty (1975) reveals that those who reject the mental illness label will tend to improve
compared to those who accept it.
Study: Langer and Abelson (1974)
Aim: testing social perception
Method: Observational Study
Description: Showed videotape of a young man telling an older man about his job
experience, and when the viewers were told beforehand that this young man was a
job applicant, the viewers perceived him differently than when they were told that
he was a patient, which led them to analyze him and judge that he was frightened
of his own aggressive impulses.
Conclusion: Shows that power of schema processing
Strength: Gives insight into schema processing and the way in which the social
setting plays a bigger role than personality in explaining behavior.
Limitations: Observational study therefore no cause and effect relationship; and
deceit took place.
 Types of bias affecting the validity of diagnosis
-Racial/ethnic
Study: Jenkins-Hall and Sacco (1991)
Aim: See whether race affects diagnosis
Method: Interview or overt observation
Description: gave European American therapists a video to watch of a
clinical interview and to evaluate the female patient. 4 conditions
representing combinations of race and depression (African American
non-depressed) (European American depressed) (AA depressed) (EA not
depressed)
 Conclusion: Ratings of depressed women differed because they rated AA
women with more negative terms and saw her as less socially competent
than the EA woman.
-Confirmation bias
Clinicians assume that if the patient is there in the first place, there must be
some disorder to diagnose  therefore they consider many people to be
abnormal even if they aren’t.
Study: Rosenhan (1973)
Aim: Wanted to test the reliability of psychiatric diagnosis
Method: Covert observation
Description: Normal people admitted to psychiatric hospitals and 19
abnormal people were released
Conclusion: Lack of scientific evidence in which medical diagnoses can be
made (using DSM-III to diagnose people)
Strengths: Insight
Limitations: Deception to psychiatrists, observational study cant see cause
and effect
*institutionalization= as soon as the participants in Rosenan’s study were
admitted to the hospital, they weren’t directly let out when they told the
doctors the truth because their actions were considered to be symptoms of
the abnormality.*
-Powerlessness and depersonalization
Lack of rights, constructive activity, choice, and privacy, and even verbal
and physical abuse from attendants.

Cultural Considerations
 Conceptions of abnormality differ between cultures which can affect the validity of the of
diagnosis of mental disorders ∴ psychiatrists should be careful of cultural biases
 Some abnormalities can be considered to be universal (emics); however, they are
culture-bound syndromes meaning they are culturally specific (etics)
o Example: Shenjing Shuairuo (neurasthenia) is a disorder specific to Chinese
people; therefore, this disorder is included in the CCMD-2 but not in the DSM-IV
o Fernando (1988): Although the APA included culture bound syndromes in the
appendix of the DSM-IV, as long as these syndromes are limited to other cultures,
they will not be admitted into western classification that could lead to
misdiagnosis and improper treatment.
 Example: Depression is found in western culture, but absent in Asian
cultures.
o Asians have ready access to social support due to it being a collectivist culture.
o Rack (1982): Asians only report physical problems related to depression not
emotional distress as they intend to sort it out within the family.
 Reporting bias causes cross cultural comparison to be difficult
  Reporting bias: low admission rates found in many ethnic groups may reflect
cultural beliefs about mental health
o Cohen (1988): mentally ill people in India are looked down upon
 Some could argue that it is not just the misinterpretation of diagnosis data, but the real
differences exist between the actual symptoms of different cultures.
o Marsella (2003): depression is more affective (emotional) in individualistic cultures,
while it is more somatic (physiological) in collectivist cultures such as headaches
o Depressive symptom patterns differ across culture because of the cultural variation in
sources of stress, as well as resources for coping with stress.
 Cultural blindness may lead to problems with identifying symptoms of a psychological
disorder if they are not the norm in the clinician’s own culture.
o Rack (1982): if someone from a minority exhibits same symptoms of a western
person, they are diagnosed with the same disorder but that might not be the case
 To avoid cultural biases:
o Learn about different cultures
o Bilingual patients should be evaluated in both languages
o Psychiatrists should work with local practitioners

7. Analyse etiologies (in terms of biological, cognitive, and/or sociocultural factors) of one disorder
from 2 of the following groups (anxiety disorders, affective disorders, eating disorders)
DEPRESSION
Biological
 Genetic predisposition can partly explain depression
- The way to see this is by twin studies = Nurnberger and Gershon (1982) found
the concordance rate for major depressive disorder was consistently higher for
MZ twins (65%) than for DZ twins (14%)
- Duenwald (2003) suggested that a short variant of the 5-HTT gene may be
associated with higher risk of depression. (This gene plays a role in serotonin
pathways and scientists think that this controls mood, emotions, aggression,
sleep, and anxiety.
-
 Depression ay be caused by a deficiency in neurobiological systems (neurotransmitters and
hormones)
-Catecholamine hypothesis (Joseph Schildkraut 1965) = depression is associated with low
levels of noradrenaline  also called the serotonin hypothesis (serotonin is the neurotransmitter
responsible for depression)
- Janowsky et al (1972) conducted a study tat showed that drugs which decrease the
level of noradrenaline end to produce depression-like symptoms. [Participants given
drug called physostigmine  depression] *The fact that depression can be artificially
induced by a certain drug  means that some cases of depression can stem from a
disturbance in neurotransmission.
-Cortisol hypothesis = (cortisol is a major hormone of the stress system)
- Stress can predispose a person to psychological and physical disorders (depressed
people have high levels of cortisol)
 - High levels of cortisol may lower the density of serotonin receptors and impair the
function of receptors of noradrenaline
- High amount of depression among people who have Cushing’s syndrome (disease
that results in a lot of production of cortisol)

 Gender: Hormonal differences may affect brain development  have different

vulnerabilities. Also, estrogen increases cortisol secretion and decreased the coritol’s
ability to shut down its own secretion  more depression in women.
Cognitive
 Elis (1962) proposed the cognitive style theory = psychological disturbances often come
from irrational and illogical thinking
 Beck (1976) = cognitive distortion theory of depression is based on schema processing
where stored schemas about the self interfere with information processing
-Negative cognition
-Overgeneralization based on negative events
-Non-logical inference about the self
-Dichotomous thinking (black and white thinking) selective recall of
negative consequences
 Negative cognitive schemas = activated by stressful events (depressed people overreact)
Sociocultural
 Brown and Harris (1978) discovered that life events that resembled previous experiences
were more likely to lead to depression.
-Vulnerability model of depression (unemployment, no social support…)
 Diathesis-stress model claims that depression may be the result of hereditary
predisposition, with precipitating events in the environment
 WHO (1983) = common symptoms of depression in Iran, Japan, Canada, and Switzerland
 Prince (1968) = no depression in Africa and many regions in Asia, but depression rates rose
with westernization in the former colonial countries
 Kleinman (1982) = Chinese rarely complain about feeling depressed
 Marsella = Affective symptoms (loneliness, isolation) are typical of individualistic cultures.
But in collectivist cultures, somatic symptoms (headaches) are more common

*Depression is not exactly the same around the world*

STUDY: The theory of social factors in depression (Brown and Harris, 1978)
Aim: Examine relationship between social factors and depression in a group of women in
London

Studied women who received hospital treatment for depression, women who visited their
doctor seeking help for depression, and the general population sample of 458 women (ages =
18 – 65 years)
 Findings = 82% of depressed had experienced a severe life event compared to 33% of the
non-depressed group
-General population Working class = 23% depressed compared to middle class (3%)
- More children = more depressed compared to childless
- Women who were widowed, divorced, or separated = depressed
- Only a minority of 20 % of the women who experienced severe difficulties became
depressed

Conclusion = BIO COG AND SC FACTORS ARE ALL IMPORTANT, BUT

SOCIOCULTURAL TIES THEM TOGETHER because the situation affects these
factors as shown in Brown and Harris’ study.

BULIMIA
 Biological, cognitive and sociocultural levels of analysis apply to the etiology of bulimia
nervosa.
 In my opinion the biological and cognitive factors of bulimia set the ground for the disorder,
and the sociocultural factors trigger the disorder.

Biological:
 Twin research show that genes play a role in bulimia nervosa
o Strober (2000) found that women with first-degree relatives were 10 times more likely
to inherit the disorder.
 Increased serotonin  medial hypothalamus is stimulated  decreased food intake
o Carraso (2000) found bulimic had lower levels of serotonin

Cognitive:
 Body-image distortion hypothesis
o Delusion of being fat
o Patients use their emotional appraisal rather than perceptual appraisal when evaluating
their body size
o Uncertain about their size and shape of their own body  overestimate body size
 Gender differences
o Men and women were surveyed about their own shape, ideal figure and figure they
thought would be most attractive to opposite sex
o Women tended to choose thinner body shapes for all three choices
 Cognitive disinhibition: “all or nothing approach” to judging oneself  strict dieting 
breaking diet will lead to binge eating
 However, the cognitive explanation is limited as it only is descriptive not explanatory.

Sociocultural:
 Perfect body image changes over time and is becoming more and more thin
 Film starts represent ideal body size
 People constantly compare themselves to other people  self esteem is affected
 Media images and message influence their desire to be thin
 Sanders and Bazalgette (1993): dolls sizes are emphasized to be skinny
 Distorted ideas about what is normal and acceptable  dissatisfaction with own shape
 By the age of 12, girls begin self evaluate their shape
 Social pressure and cultural pressure leads to bulimia

8. Examine biomedical, individual and group approaches to treatment.

Treatments affect people at all levels of analysis:
1. Brain
2. Thinking
3. Perception and acceptance of treatment

Biomedical, individual and group treatment is over simplistic if a patient uses only one treatment.

Treatment choice depends on many factors:

- Severity of symptoms
- Cause of the problem
- Cultural beliefs
- Presence of other mental and/or physical health problems

No one treatment works for everyone. Some people do not respond to the treatment. Some people get
better without any formal treatment.
 professionals use more than one treatment at the same time = eclectic approach