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Discuss the issue of bias in diagnostic system
Different patients with the same syndrome (e.g. schizophrenia) rarely present the same
symptoms. There is a grey area in which the fit between a patient's symptoms and those
forming the syndrome of a diagnostic category is relatively poor. In such cases, it is hard to
know whether or not the diagnostic category is appropriate.
The diagnostic systems developed in Western Psychological medicine are the DSM
(diagnostic statistical manual of mental disorders) in the USA and ICD (international
classification of diseases) in Europe. Both diagnostic systems have been modified over time
to fit in with the society and what people consider is normal or abnormal.
A classic study by Rosenhan (1973) raised serious questions about the reliability and validity
of psychiatric diagnoses. "Pseudopatients" were diagnosed as schizophrenic and in the
second study; real patients were sometimes identified as pseudopatients. It may be that
psychiatrists are more inclined to call a healthy person sick rather than a sick person healthy
because it is potentially dangerous to release a sick person without treatment. Rosenhan
calls this a "type two error", a false judgement made in order to avoid failing to diagnose a
real illness. In the case of failing to correctly diagnose a real patient, it may be that
psychiatrists were now making more type one errors (calling a sick person healthy) because
they were trying to avoid making type two errors.
According to Davison et al (2004), despite some categories still having greater reliability than
others, reliability has improved significantly since the publication of DSM-III in 1980 and is
now acceptable for major categories. However problems remain; specifying a particular
number of symptoms from a longer list that must be evident before a particular diagnosis
can be made seem very arbitrary. There's still room for subjective interpretation on the part
of the psychiatrist. For example, in relation to mania, the elevated mood must be
`abnormally and persistently elevated' for a diagnosis of mania to be made. Davison et al
(2004) says, `such judgements set the stage for the insertion of cultural biases as well as
the clinician's own personal ideas of what the average person should be doing at a given
stage of life'.
However Clare (1980) argues that the nature of physical illness isn't as clear-cut as critics
claim; reliability between doctors regarding angina, emphysema and tonsillitis is no better
than for schizophrenia (Falek and Moser, 1975). Clare believes that psychiatrists are at fault,
not the process of diagnosis itself. Classification systems such as DSM and ICD are based on
the assumption that we can assign individuals neatly to certain categories. However, many
of the symptoms defining their categories are found in the majority of the population. For
example, the key symptom of panic disorder is the existence of recurring panic attacks. On
the other hand, Norton, Doward and Cox (1986) found that 35% of college students had
experienced one or more DSM-III defined panic attacks over the preceding year. In similar
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Rachman and de silva (1978) found that the obsessions and compulsions found in
patients with obsessive compulsive disorder are also found in over half the `normal'
population. Such findings make it hard to justify the notion of neat categories. One problem
with these findings is that it is culture biased because it is assumed that studies done in
western populations can be generalised to other populations such as Asian or African
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The result is that `normal'
female behaviours are often seen as signs of illness. For example, the clinical characteristics
for anorexia nervosa include lack of menstrual periods but men also suffer from anorexia.
Support for this comes from Ford and Widiger (1989) who gave psychiatrists written cases
to diagnose. Histrionic personality disorder was correctly diagnosed 80% of the time when
the patient was said to be female, and 30% of the time when male.…read more