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Post by alison on Mar 1, 2016 12:14:34 GMT
I agree with the text in this module that a big issue in psychiatric diagnosis is the fact that there are no clear boundaries between mental disorder and normality.
With increasing constraints on resources in health services, I feel there comes increasing risk of inappropriate psychiatric diagnosis – particularly at primary care level.
I spoke to a GP friend and her view is: “Where there is any doubt, it is safer and more appropriate to under-diagnose than to over-diagnose. It is always easier to ‘step up’ to a more severe diagnosis than to step down from it, once it has been given”.
I agree with this view. But in practice, how often as therapists, do we see examples of ‘normal life’ being given a psychiatric diagnosis? For example: ‘normal’ grief diagnosed and treated as depression?
There are so many questions around diagnosis of mental health issues. What purpose is the diagnosis serving? What are the implications of the diagnosis for the patient? What is the relationship between budgetary constraints in the NHS and psychiatric diagnosis? What is the relationship between aggressive marketing tactics of pharmaceutical companies and psychiatric diagnosis? How often does the label of a psychiatric diagnosis lead to inappropriate treatment? How accurate is the diagnosis – have all factors been sufficiently considered?
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Post by alison on Mar 1, 2016 13:14:57 GMT
Accurate diagnosis can bring many benefits: including safety and effective and appropriate treatment. Another perspective is that for some people psychiatric diagnosis is very important in terms of their entitlement to certain state benefits. Without an accurate diagnosis, people too unwell to work/support themselves are extremely vulnerable and this vulnerability is exacerbated further if the lack of diagnosis prevents entitlement to certain disability benefits, carers allowances etc. The Institute for Fiscal Studies reports a 'dramatic rise' in the proportion of disability claims related to mental illness (risen from 27% to 41% since 1999). The Telegraph reports the IFS Director as saying it is "implausible that people have become more mentally unhealthy on this scale and time horizon". That's quite an 'interesting' statement to reflect on in context of new DSM-5 and of course the change of government also, since 1999. See: www.telegraph.co.uk/news/health/11622166/Nearly-half-disability-benefit-claimants-have-a-mental-illness.htmlThis article includes statements from employers, which is quite interesting in relation to earlier thread (started by Peter, re: manipulation of assessment scores). The vulnerability of those living with mental illness is undeniable. Crisis, the homeless charity, reports that the prevalence of common mental health problems in the homeless population is twice as high as it is in the adult population in the UK. And psychosis is 4-15 times higher in the homeless population. |
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Post by alison on Mar 1, 2016 14:09:23 GMT
I find the mind-body dualism of psychiatric diagnosis problematic, and for me, the inclusion of somatisation disorder in DSM-5 is an example:
The psychiatric label ‘somatisation disorder’ is overly simplistic. In ‘Somatic Illness and the Patient’s Other Story’ Brian Broom (1997) says: “widely used psychiatric terms such as ‘somatisation disorder’ have some validity but imply a dualistic and linear mind-body mechanism, as if: I am putting my emotions into my body; I am transferring them from one compartment to another” (P. 22).
According to Broom, the ‘decision’ as to whether the phenomenon is expressed in the mind or in the body is influenced by what APPEARS to come first in the chain of events. For instance, which experience (mental or bodily) is perceived first by client, doctor or therapist? Many people find it easier to define their physical states than their emotional states – and so pick up on the onset of the former earlier than the latter and immediately assume that the physical symptom preceded, for example, the drop in mood.
There is extensive evidence (for example, Burton 2003) that rejects the notion of a linear (mind then body) process.
Burton, C. (2003) Beyond somatisation: a review of the understanding and treatment of medically unexplained physical symptoms (MUPS). British Journal of General Practice, 53(488) P. 231-239
Recent studies recognise the occurrence of medically unexplained physical symptoms as part of a complex, adaptive system.
In this model, people diagnosed with somatisation disorder may best be viewed as having complex adaptive systems in which cognitive and physiological process interact with each other and with their environment.
Contemporary psychotherapy recognises this complex adaptive system:
For example Pamela Gawler-Wright (Director of BeeLeaf Contemporary Psychotherapy) understands the contemporary psychotherapist as:
“Responsively pacing the development over time of the client, is aware of the “biological timepiece” that is the human body and the crucial engagement of the somatic intelligence in affecting positive psychotherapeutic change. Effective treatment is sympathetic and sensitive to the innate circadian and ultradian rhythms of the human biological and affective systems that are observable to the trained practitioner who is able to synchronise to and utilise these cycles, also called “trance”, “hypnosis” or “altered state”, to facilitate the client’s process of change” (taken from BeeLeaf website).
There is extensive evidence of mind-body links, and the 'complex adaptive system' in the literature. In many ways, psychiatric diagnosis is a complete rejection of available evidence.
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tutor
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Post by tutor on Mar 2, 2016 10:33:01 GMT
Hi Alison
I agree with your comments. You have clearly given this much thought. What do the others think - don't be shy!
Tutor
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Clare
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Post by Clare on Mar 3, 2016 14:25:01 GMT
Diagnosis of mental health issues can be a positive outcome for the person, it may mean there is intervention by mental health team and a person’s life may change for the better.
The opposite outcome, a person is labelled and blames their behaviour on the label without taking responsibility for negative behaviours.
There is no scientific diagnostic tool that creates the definitive lines between what is normal and abnormal psychological functioning, so is there too much diagnosing to establish these disorders?
“Social construction of psychopathology works something like this. Someone observes a pattern of behaving, feeling, thinking that deviates from the social norm. A group of influencers decides that control, prevention or treatment is desirable. Once a condition becomes a disorder and written in a diagnostic manual, it then takes an existence of its own and becomes disease like.” Maddux J. p.12
Maddux then states “methods of science can study it, but the construction is social and not a scientific one."
Each time the DSM is revised and re-published there are more and more disorders, are we in danger of over diagnosing what are common problems in life? For example, will an introverted shy person be labelled with social anxiety?
Developmental psychopathology, in contrast to clinical psychology,
“It does not focus on the diagnosis, treatment or prognosis but rather interested in the pathways that lead toward and away from disorder” Maddux J. (2016) p.18
And then we have neurolobiological psychopathology which is more biologically orientated -
Gene discovery work in ADHD is proceeding with significant associations with dopamine neurotransmission, particularly the dopamine transporter gene. Maddux J. (2016) p.50
The cause of psychopathology gets more interesting, from molecular level to social & cultural, then maybe as new and more experienced therapists studying this topic we can understand, integrate these different levels of explanation to give a fuller picture on mental health.
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Maddux. James et al (2016). Psychopathology. Foundations for a Contemporary Understanding. 4th ED. Routledge London & new York
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Clare
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Post by Clare on Mar 3, 2016 14:33:37 GMT
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tutor
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Post by tutor on Mar 6, 2016 6:36:55 GMT
Hi Alison and Clarem
There is a quote - "Remember to talk to your client and not to your theories"
Certain psychiatric diagnoses such as bipolar disorder open up therapeutic opportunities that only work in that situation. If a diagnosis is made - is it useful foe psychotherapy?
Tutor
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Post by Chris on Mar 6, 2016 14:05:27 GMT
I am reminded of the Rosenhan Experiment of the early 1970s in particular: en.wikipedia.org/wiki/Rosenhan_experimentand the direction of the anti-psychiatry movement in general, which considers psychiatry to be an instrument of oppression due to an unequal power relationship between doctor and patient, and a highly subjective diagnostic process. With many of the psychiatrists and writers associated with the anti-psychiatry movement, economic, social, sexual and class inequalities went hand-in-hand with psychological distress. If you didn't address these issues with the patient, you were merely returning them to the conditions which made them unwell in the first place. |
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Post by alison on Mar 8, 2016 14:44:52 GMT
I recall our Stage 2 tutor often saying to our group: be sure you're working with the client that is in the room, not the client that is in your head. Tutor quote above is a helpful reminder of that advice! I think it is helpful to remain mindful of this, as it could be all too easy to fall into working with 'the diagnosis' rather than the client.
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