The problems with diagnosing dysfunctional behaviour (and a great audio podcast on abnormality)

Here is an absolutely brilliant audio podcast from Todd Daniels, entitled "What is Normal?" He's a psychologist from the US, and he's got 50 audio podcasts on a range of issues. He explains things with plenty of examples, and I think it's definitely worth checking out. It's a little lengthy though, so here are some of the main issues:

Dysfunctional behaviour is a tricky term to define. Here's a working definition generally used by the psychology community:

It is behaviour which is deviant, maladaptive, and personally distressing. 

It fits pretty well with Rosenhan and Seligman's definition, too. Statistical infrequency, deviation from ideal mental health and deviation from social norms all links to the characteristic of "deviant", and failure to function adequately comes under both "maladaptive" and "personally distressing".

So, it seems like a great definition. But, there are limitations.

Not all behaviours considered dysfunctional have all three characteristics - so can they be defined as dysfunctional or abnormal? Sometimes. Smoking is an addiction, but unlike most addictions, it's not really considered dysfunctional, even though it's maladaptive and most find it personally distressing. On the other hand, depression is considered dysfunctional, even though it's likely more people suffer from depression than get addicted to cigarettes.

So, a major problem with diagnosing dysfunctional behaviour is not only defining it, but knowing how many characteristics of the definition behaviour has to exhibit to be labelled as dysfunctional.

Another problem is subjectivity, which leads to both poor validity and poor reliability. Whilst the DSM attempts to standardise diagnoses, the person who's diagnosing the disorder has room for subjectivity. For example, the DSM criteria for a phobia states that in order to be diagnosed, the fear of the object or situation must be "excessive". But, what's excessive? It changes according to the person. If the psychologist also fears the object, they might think there's a higher threshold for excessive than somebody who doesn't understand or share the same fear. So, a lot of diagnoses are actually based on bias of other people. Definitions also suffer from this weakness, as seen in the "observer discomfort" criterion for failure to function inadequately. Thus, there is unlikely to be uniformity in diagnoses, which leads to poor internal validity due to the confounding variable of bias, as well as poor reliability due to the individual differences of clinicians. 

Ethnocentrism is also an issue, related to this. Depending on our own culture, we may or may not perceive a behaviour to be abnormal. For example, if a man were to wear clothes such as dresses, or skirts, this in many Western cultures could be labelled as both deviant, and causing observer discomfort. It's statistically infrequent, and deviates from social norms. However, in Scotland for example, men wear kilts, which are essentially skirts. And, in the LGBT community, it wouldn't be considered abnormal. So, there's a fair amount of ethnocentrism within diagnoses. It's a fairly similar point to subjectivity, but you can extend it to points such as the fact that diagnoses cannot be generalised externally due to lacking population validity in other communities. They're also likely to lack temporal validity, due to the changing nature of cultures. Furthermore, it's arguable that the concept of dysfunctional behaviour lacks construct validity, as it's difficult to define. And thus, is it really nomothetic? 

Essentially, diagnosing dysfunctional behaviour is complex and often inaccurate. 

Full mark part b) question

G543 Applied Question (June 2010)

Diagnosing dysfunctional behaviour

b) Discuss limitations of diagnosing dysfunctional behaviour

(15 marks)

In order to treat dysfunctional behaviour and help people through clinical psychology, it is necessary to diagnose dysfunctional behaviour, which consists of both defining what dysfunctional behaviour is, and then classifying it. However, with both of these steps, there are limitations. Furthermore, actually implementing the diagnoses, even after classifying it with the DSM or ICD, has limitations of subjectivity.

One of the main limitations of diagnosing dysfunctional behaviour is actually trying to define what dysfunctional behaviour is, because everybody varies, and what one person sees as dysfunctional may actually be quite normal or adaptive for somebody else.  This could be seen in Rosenhan’s study “On being sane in insane places”, where behaviour such as waiting for food was misinterpreted as the participant being “oral-acquisitive”. Rosenhan and Seligman formulated criteria for defining behaviour as dysfunctional, but this has limited validity for a number of reasons. For example, the inclusion of Jahoda’s list of “ideal mental health” is actually very ethnocentric as it is more of a part of Western culture to act independently, whereas many Eastern cultures are more concerned with the group dynamic. This makes the list less useful and nomothetic, as it cannot be reliably applied to all people. Similarly, deviation from social norms is one of the four criteria, but this would mean that behaviour exhibited that caused the feminist and civil rights movements, as well as anybody who was homosexual, would be labelled as dysfunctional. The list is too simplistic and reductionist, because it doesn’t take into account that people vary so significantly that a few criteria on a list, or how statistically rare a behaviour is does not make it any more or less dysfunctional, as depression is more common than an IQ over 130, though most would see the latter as more preferable. If we are unable to correctly define dysfunctional behaviour, this means construct validity is weakened, and we may be unable to tell what behaviours are actually maladaptive and negative for the individual, and thus be unable to treat it properly.

A further issue with ethnocentrism, which is a limitation of diagnosing dysfunctional behaviour, is that there tends to be gender bias when diagnosing certain disorders. Ford and Widiger’s (1989) study demonstrated how females are more likely to be correctly diagnosed with HPD and males are more likely to be diagnosed with ASPD, which shows that even experienced clinical psychologists have a tendency towards gender stereotyping. Despite the ICD and DSM, it appears that diagnosing dysfunctional behaviour is actually somewhat subjective and therefore diagnoses may lack face validity. As diagnoses tend to be ethnocentric in terms of both gender and culture, it appears that diagnoses of certain disorders made, particularly if they refer to the DSM rather than the ICD, will favour and be more generalizable to one gender and countries in Europe and North America rather than Asia, which ultimately makes diagnoses less applicable and useful.

There are two main manuals used for categorizing dysfunctional behaviour: the ICD and the DSM. However, there are inconsistencies, which result in differences between the main manuals used, and thus how you are diagnosed is affected by the manual that is used. For example, the DSM is more holistic as its fourth and fifth axes take into account social and external factors, whilst the ICD is more symptom-based and has more specific categorization of mental disorders. This means that diagnosis of disorders is likely to be somewhat unreliable, and this makes it more difficult to treat patients efficiently as they may be misdiagnosed. This could also be somewhat dangerous, as giving the wrong medication to a patient breaks ethical guidelines of protection from harm, and may actually worsen their condition. The poor reliability therefore implies that there is an issue with validity, which reduces the usefulness of the manuals and diagnoses themselves.

Thus, the main limitations of diagnosing dysfunctional behaviour include subjectivity, validity, reliability and ethnocentrism. The proposed introduction of a DSM based on biological symptoms instead of behavioural symptoms could potentially go some way to reducing these limitations, but for now, it is better than there are classification systems and definitions that are not perfect than having no way to diagnose and thus treat dysfunctional behaviour at all. 

Why the DSM-V is dividing psychiatry (and why you need to know this)

It's not strictly in the syllabus, but if you can fit this seamlessly into an exam question on diagnosing dysfunctional behaviour or disorders, then no doubt the examiner will be impressed.

If you've got a spare ten minutes, check out this article from the New Scientist on opposition to the DSM-V, and why the National Institute of Mental Health has withdrawn its support to the publication of the DSM-V. If not, read my very much condensed summary below.

The DSM-V is due out later this month (May 2013), replacing the current DSM-IV that's been around since the mid-1990s. Essentially, there's been a lot of complaints about the amount of reliance, by both the medical profession and researchers alike, on a psychiatry "bible". 

The main issue is that it's purely symptomatic - it ignores the biological nature of disorders.

Those who advocate psychology as a science want the biological and physical aspects of psychological disorders to be taken into account so that subjectivity isn't such an issue. They use the comparison of being diagnosed with physical illnesses such as cancer on the basis of self-report alone, rather than being screened and tested. (Though, note that not all "physical" illnesses can be tested for, such as IBS). 

Some of the more radical people want the DSM completely scrapped in favour of a biological approach to diagnosis, such as depression being diagnosed on the basis of serotonin, or schizophrenia after dopamine levels have been analysed. Others merely want both symptoms and biology to play a part in diagnosis.

Whatever you think is the right decision, including this in your G543 paper would show your interest in the subject, and could be a valuable evaluation point which makes the examiners stand up and take note. 

Gender biases in DIAGNOSING DYSFUNCTIONAL BEHAVIOUR

The DSM-IV (soon to be DSM-V) and ICD-10 are intended to make diagnoses as valid and reliable as possible. But there's still only 50% agreement between clinicians in diagnoses, which suggests that subjectivity plays a significant part in diagnoses.

Thus far, we've seen from Rosenhan and Seligman that diagnosing dysfunctional behaviour is fairly subjective and ethnocentric. 

But diagnoses of disorders can also be affected by gender. Gender biases in diagnoses leads to poor reliability and validity, and could actually be life-threatening if someone is treated for the wrong disorder; and even if it wasn't, prescribing medication or therapy for a misdiagnosis is not desirable. 

One piece of research into gender bias is Ford and Widiger (1989). They aimed to find out if clinical psychologists were gender stereotyping when it came to diagnosing certain disorders, namely histrionic personality disorder and anti-social personality disorder.

Histrionic personality disorder (HPD) is a personality disorder which is characterised by seductive, manipulative behaviour, shallow expression of emotions and attention-seeking. For this reason, it's often stereotyped as a "female" disorder as it fits in with common stereotypes of women. Anti-social personality disorder (ASPD) is characterised by aggressive behaviour and impulsivity, and thus is often stereotyped as a "male" disorder. N.B both genders can have either personality disorder.

A sample of 266 clinical psychologists made diagnoses based on the information given to them, thus it was an experiment using self-report measures. The IV was the gender of the patient, and the DV was the diagnosis given. 

Participants were given anonymous case studies with the only detail being gender and were asked to identify the disorder. The case studies documented cases of HPD, ASPD, and patients with symptoms from the two disorders in an equal mix. 

ASPD was correctly documented in males considerably more than with females (42% to 15%), and the reverse was found in HPD as females were correctly diagnosed with HPD considerably more often than males (76% to 44%). This suggested that clinical psychologists, even with considerable clinical experience, gender stereotype certain disorders, and also that males were perhaps taken more seriously rather than being judged negatively for their gender, as they were misdiagnosed less often. 

The problems with DEFINING DYSFUNCTIONAL BEHAVIOUR

What is dysfunctional behaviour? It's a tricky question that not even the professionals can easily describe. The simplest definition is "behaviour which disrupts normal functioning such as social interaction and sustaining employment", but it's still pretty broad.

Rosenhan and Seligman (1984) attempted to define dysfunctional behaviour. They created four criteria for "abnormality" (this used to be the official term for what is now dysfunctional behaviour):

1. Statistical infrequency (if a behaviour is statistically very rare, it could be dysfunctional)
2. Deviation from social norms (if a behaviour is not "normal", it may be dysfunctional)
3. Failure to function adequately (such as causing observer discomfort and being irrational)
4. Deviation from ideal mental health (Jahoda's 7 criteria including aspects such as being able to act independently and having positive self-esteem)

Some of these criteria may seem fairly logical if you think about the term dysfunctional, however it would label the following behaviours as dysfunctional at one point or another: homosexuality, protesting (e.g. civil rights movement or feminism), inventions, science, having a high IQ, winning the lottery, e.t.c.

So, it's not ideal. It's also pretty ethnocentric. For example, the criterion of "being able to act independently" would actually be seen as dysfunctional in some cultures, as group decisions and democracy are seen as prevalent. Statistical infrequency would render high IQ dysfunctional, but depression functional. And everyone is irrational or has low self-esteem at one point or another; does that mean we necessarily all have a psychological disorder?

Evaluation issues for this section would include subjectivity, cultural bias, ethnocentrism, temporal validity, face validity and construct validity, as well as reliability. 

Comparing the DSM and ICD

There are two main manuals that are used in order to categorize mental disorders: the DSM and ICD.

Similarities:

• Both are diagnosis and categorizing manuals which require two or more symptoms to be present in order for the diagnosis to be made.
• They aren't self-diagnosis manuals; they're intended to be used by qualified health professions, and more specifically psychiatrists.
• Both are officially recognised manuals used to categorize and diagnose mental disorders. 

Differences:

• The ICD is used internationally, and was published by WHO (World Health Organisation) whilst the DSM was created by the American Psychological Association and is used primarily in the USA. Often, British research tends to use the DSM in order to fit in with American research, as most psychological research that is published and widely known is conduced in the US.
• What it includes. The ICD is a much larger manual and encompasses all types of disorders; only chapter V is relevant for mental disorders. The DSM is purely for mental disorders.
• The DSM requires the psychiatrist to evaluate the patient in five axes whilst the ICD is more symptom-based, and it also includes more groups of mental disorders with 10 in total.    
  
  ICD: includes 10 groups such as delusional disorders, mood disorders, etc. and clinical/personality disorders are part of the same group.
  
  DSM:
1. Clinical disorders (such as depression)
2. Personality disorders (such as mental retardation)
3. Physical health
4. Environmental factors (optional)
5. Global assessment of functioning (optional)