This demonstrates several important problems within diagnosis. Firstly, regional variation in training affects diagnosis and the use of a classification system does little in the way of ironing out the subjectivity of the clinician. Secondly, variations in diagnosis have important implications for epidemiological data contained in both the ICD and the DSM. The subjectivity of a clinicians(s) diagnosis is likely to give an unreliable picture of a disorder – information that may be used in a later version of either classification system.
More recently Langwielder & Linden (1993) studied different clinicians techniques, and found that different doctors obtain different information from the same patient, and form different conclusions. (Journal of Affective Disorders (27) p1-12)The tests used in conjunction with classification systems vary at the discretion of the psychiatrist and conceivably, identify different areas of behaviour, thus providing different information on which to base a diagnosis. Arguably, in order for clinicians to agree, and classification systems to be objectively reliable, they must use the same methods of extracting information. However it could be seen as a methodological fault in the classification system for not specifying which tests to use.
Okasha et al’s study provides evidence to support the view that diagnosis differs because of variation in techniques. By “training clinicians to use specific criteria and standardised interviews”, Okasha demonstrated that agreement in diagnosis is more likely to improve. (in Cave p65 1993) Significantly, Copeland et al, Langwielder & Linden and Okasha’s studies suggest that it is not the classification systems that are unreliable; rather it is the clinicians, who because they differ in terms of locality, techniques, social background, and current training, cannot themselves produce consistent results.
Although there is evidence to suggest that clinicians are accountable for the unreliability in diagnosis, it is also permissible to propose that the problem lies in the lack of homogeneity of the categories in both systems. The DSM diagnostic category of Multiple Personality Disorder (MPD) is a good example to demonstrate this problem. In a study, North (1993) found that most patients diagnosed with MPD also fulfilled the criteria for Depression, Antisocial Personality Disorder, and Schizophrenia. Conceivably, any one of these disorders could have been diagnosed instead of MPD, which highlights the similarity of the symptoms between the different disorders. (North et al p75 1993) The occurrence of comorbidity (having more than one disorder at the same time) is also a factor that discredits the homogeneity of the categories. Some disorders are regularly diagnosed together such as depression, anxiety, and manic depression suggesting that such disorders are not separate categories but perhaps dimensions of one category. The lack of homogeneity apparent in the categories of both systems indicates they are not descriptively valid, and as such cannot be regarded as scientifically accurate. Moreover, it is difficult to understand how any reliability is achieved when patients’ either have symptoms are characteristic of several disorders at once, or have several disorders at the same time. Significantly, the implications of inaccurate categories would render any research (for example into treatments or causes) invalid.
Critics of present classificatory systems also point out the lack of knowledge regarding what causes most mental disorders to occur. Indeed, Mackay argues, (in Gross, p958 1996) the point of having a tool for diagnosis is that it provides psychiatrists with a label by which to make a judgement in terms of, what caused the disorder to occur, and the most appropriate type of treatment. In cases of Schizophrenia it has been diagnosed in both patients with a family history of the disorder and in patients without (Cave p67 2002). Yet for the disorder to be an aetiologically valid diagnosis, the causes should always be the same. Treatments for many mental disorders also vary, which gives the diagnostic process little value in terms of predictive validity. Heather notes,“ there is only a 50% chance of correctly predicting what treatment a patient will receive on the basis of diagnosis” (in Gross 1996 P958) Pointedly, if the diagnostic label a patient is given does little in terms of providing help to treat the disorder then its consequences are arguably negative.
A further concern regarding classification systems is one of the ethical consequences of diagnosis. Some psychologists argue that by diagnosing a patient, clinicians are applying a label, which effectively produces the disordered behaviour. Becker’s labelling theory, surmises that when an individual is labelled, (thief, alcoholic, schizophrenic), the label becomes the master status, in terms of how the individual is perceived, and treated. This is exemplified in Rosenhan’s famous, ‘On being sane in insane places’ study (1973). Eight (‘psychologically normal’) researchers presented themselves at different psychiatrist hospitals, complaining of hearing a voice saying hollow, bump and thud. Most were admitted with a diagnosis of Schizophrenia. After admission, each ‘patient’ announced the voices had stopped, and he/she was back to normal. Psychiatrists and nurses observing their behaviour noted actions such as writing notes, and pacing up and down the corridor, as signs of pathological behaviour and nervousness. Most patients were discharged with diagnoses’ of schizophrenia in remission, their stay lasting between 7 and 52 days. (Rosenhan, D. L. 1973 in Bilton et al p608 2002). Thus, the patient with a ‘master status’ of ‘Schizophrenic’, is perceived by others (psychiatrists) in terms of the label. Behaviour is interpreted as symptomatic of the disorder, which helps to reinforce the diagnostic label. Psychologists argue that the implications of labelling for ‘real’ patients, would have the effect of creating a process known as the self-fulfilling prophecy, i.e. the patient begins to see him/herself in terms of the label applied and behaves in ways associated with it. Thus the disordered behaviour is perpetuated. (Haralambos, M. et al p784 2000)
Clearly then, the process of diagnosis (labelling) has a significant effect on the patient. It serves to place a label on the patient, which is difficult to remove, (hence most patients in Rosenhan’s study were discharged with schizophrenia in remission). More significantly, it encourages others to view the patient as ‘mentally ill’ which affects how he/she is subsequently treated, both medically and socially. Behaviour is seen in light of the label, which could arguably lead to prolonged illness, and social problems because of the stigma attached to a mental disorder.
Furthermore some critics argue that by labelling a patient, it has the effect of reducing the responsibility that the patient has for his/her behaviour and providing an appropriate ‘excuse’ “it is the disorder that makes them behave in this way” (Cave p72 2002). The action of diagnosis delegates’ responsibility to the psychiatrist, which is arguably unhelpful for the patient as it could limit their recovery. (Parsons 1951 in Cave p72)
If labelling is to be credited as an accurate theory, then it highlights the importance of the label in diagnosis, and the subsequent problems attached to having a ‘stigma’. It is therefore of the utmost importance that a diagnosis should be accurate, in both identification, and treatment. Thus highlighting the importance of the accuracy of a classification system.
Evidently, classification systems have several important limitations. However it is not clear as to where the blame lies. As this essay demonstrates, the different social attributes, training and techniques of a clinician can affect reliability. Yet the evidence also suggests that inaccurate or unclear diagnostic categories could affect agreement in diagnosis. Research into treatment and causes of mental disorders is likely to give a false picture because of variations in diagnosis. The evaluation of schizophrenia and multiple personality disorder categories demonstrate that as methods of assessment, classification systems have little validity in terms of predictive and causal value.
In addition, the consequences of diagnosis for the patient are several. Diagnostic labels have stigma attached, which can affect how the patient is treated both socially, and medically. As the self-fulfilling prophecy suggests, this may reinforce the disordered behaviour. The potentially negative consequences of diagnosis highlight the huge importance of accurate classification, and the need for standardised assessment tests in order to improve reliability.
Finally, although classification systems appear to have questionable reliability and validity, it remains debatable as to whether the fault lies within the systems themselves, or their subjective interpretation.
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