Diagnosis takes place in a clinical setting with a psychiatrist and an individual seeking help. The person seeking help may present a diversity of symptoms that do not necessarily conform with the psychiatrist's experience or the descriptors in classification manuals. It is recognized that there are a number of factors that could affect the validity of a diagnosis,

Clinical biases

When an individual comes into a clinic and complains about certain symptoms, the clinician will assume that he or she wants to know what is wrong and also wants a treatment. However, when we are dealing with mental disorders it is not as clear-cut as one would think.

The clinician will always have to interpret symptoms and the patient's own account and this could lead to biases even though a modern classification system is part of the diagnostic process. For example, it is known that gender, socioeconomic status, and ethnicity could influence diagnosis.

There is always a risk that a clinician may fall victim to confirmation bias. Confirmation bias is a result of schema that allow us to understand and predict a situation. In other words, the psychiatrist sees what he expects to see. Confirmation bias is influenced by both stereotyping and social norms. This can be seen in the following study by Temerlin (1970).

 Teacher only box

1.  Which experimental design was used for this study? What would be a limitation of that design?

The study used an independent samples design. The limitation of this design is participant variability.  It would be important in this study that each group had the same type of experience - both in terms of the types of patients that they worked with and the number of years that they have been practicing psychology.

2. Does this study "prove" that diagnosis is not reliable?  Why or why not?

The word "prove" is highly problematic in psychology.  What this study does show is that the group that had the "respected psychologist" give an opinion was unduly influenced by his/her suggestion.

Gender bias in diagnosis

Another consideration in diagnosis is the role of gender schema.  For some disorders, women are diagnosed more frequently than men – and vice versa.  The question is whether this is an actual gender difference, or is the higher rate of diagnosis the result of gender stereotypes?

According to statistical evidence, women are two to three times more likely to become clinically depressed than men. It is a widely held belief that women are naturally more emotional than men, and therefore more vulnerable to emotional upsets because of hormonal fluctuations. But is there any validity to this argument? Many researchers argue that the reasons for depression are rooted more in social causes than in biological ones.

Research shows girls become more susceptible to depression than boys only after puberty when they begin menstruating and experience hormonal fluxes. However, psychologists have never been able to establish a direct relationship between emotional states and levels of estrogen and progesterone in women.  Research by Vamvakopoulos and Chrousos (1993) showed that higher levels of estrogen may lead to higher levels of cortisol secretion.  If this link can be better established, it could be good support for a biological argument for the gender difference in the prevalence of depression.

As you will see in the next section of this chapter, Brown & Harris (1978) argued that women are exposed to more stressors than men are as a result of social hierarchies.  This higher level of stress could be linked to depression, demonstrating the role of the interaction of biological and social factors in the disorder.

A final reason why prevalence rates may be different is that women are over-diagnosed with depression.  Amenson & Lewinsohn (1981) tested this theory by comparing the help-seeking behavior of men and women with similar levels of self-reported depressive symptoms.  They found that both genders were equally likely to seek psychiatric help or go to a general practitioner. In addition, the researchers found that men and women with equal levels of self-reported symptoms were equally likely to be diagnosed as depressed in a clinical interview. Although it is a common belief that women are over-diagnosed, this is a theory that is difficult to support empirically.

Swami (2012) carried out an extensive study of 1218 British adults. Participants were given a paper survey to fill out in which they were given a vignette – a short description – of either a male (Jack) or a female (Kate).  The description met the diagnostic criteria for depression according to the DSM IV and the ICD-10. The vignettes were exactly identical except for the gender. After reading the vignette, the participants were asked if the individual described suffered from a mental health disorder.

The results were that participants were more likely to indicate that a male vignette did not suffer from a mental health disorder compared to a female vignette. This study may indicate that gender stereotyping has an effect on diagnosis; however, the study did not use professional psychiatrists – but instead used members of the general public.

 Teacher only box

There is no correct answer to this activity.  The goal is to get students to think about the concept of falsifiability and testability. My own thoughts are below.

It is the result of differences in income, not a result of gender stereotyping.

This is a relatively easy one to disprove. We can look at men and women at the same level of income within a culture and look at their mental health.  We do find that women have higher rates of depression and anxiety than men in all income levels in the US and the UK. This is a relatively testable hypothesis. Of course, the question for all of these hypotheses is "what counts as a diagnosis?"  Do we use self-reported symptoms, or do we need a clinical diagnosis? In the latter case, we have the problem that we cannot know that those that have not been diagnosed because they have not been to a clinic are actually healthy.

It is more difficult to diagnose in men because they have different symptoms.

This is a very difficult one to investigate.  For example, in order to be diagnosed with depression, individuals must meet a set of DSM criteria. So, to argue that they have depression but that it just has different symptoms is a bit of a circular argument.

Women’s hormones increase the likelihood of developing depression.

Theoretically, this could be tested.  However, in order to establish cause and effect, we would need experimental research.  This type of research has been done on animals, but it is problematic to diagnose "clinical depression" in animals.  Research on women's hormone levels has not been shown to be significantly linked to depression, but there are cultural factors that may affect one's mental health during menstruation, puberty, or menopause. We can carry out "natural experiments" investigating women's level of depression before and after puberty (and before and after menopause).  These studies have not shown a significant change in mental health in most individuals.

Women think more about their problems than men do.

Although some researchers, such as Nolen-Hoeksema, have made this the basis of their theory of depression, actually measuring one's "level of rumination" is very difficult since cognitive processes cannot be observed  Only indirect methods can be used to study this hypothesis - e.g. questionnaires, interviews, or fMRI scans.

Cultural bias in diagnosis

It is generally accepted that culture is a determining factor in the experience and expression of psychiatric symptoms but cultural biases may also affect diagnosis. Cochrane and Sashidharan (1996) point out that it is commonly assumed that the behaviours of the white population are normative and that any deviation from this by another ethnic group reveals some racial or cultural pathology. Conversely, as Rack (1982) points out, if a member of a minority ethnic group exhibits a set of symptoms that is similar to that of a white British-born patient, then they are assumed to be suffering from the same disorder, which may not actually be the case.

 Teacher only box

1. The aim of this study was to test the role of stereotyping on diagnosis. Do you think that this study accomplishes that? Why or why not?

It is difficult to establish the validity of this research. No test was done to determine the stereotypes and/or prejudice of each group before the study began. Because there are some differences between the white and Chinese American clinicians' responses, it is assumed that stereotyping played a role in the diagnosis - but it is not possible to determine from this study whether their diagnoses matched their stereotypes

2. Why was it important that all of the Chinese patients were born either in China or in Hong Kong?

It is important because the researchers want to make sure that they reflect Chinese culture. If they were born in the US, their education and peer groups would have had a significant effect on their cultural identity and behaviour.

3. Which of the three findings do you think is the most significant? Why is this important in a discussion of the findings?

The finding that is statistically the most significant is that the White clinicians found the Chinese patients to be more depressed. The probability that the results were due to chance increased with each of the findings. This is important, especially because the sample size was small. It is important when discussing the findings because a 5% level of probability that the results are due to chance is the maximum that we accept in psychology. Having such a high probability emphasizes the need for this study to be replicated.

One of the problems in diagnosis is that real differences exist between cultures in the symptomology of disorders. For example, Marsella (2003) argues that depression takes a primarily affective (emotional) form in individualistic cultures. In more collectivist societies, somatic (physiological) symptoms such as headaches are dominant. Depressive symptom patterns may actually differ across cultures because of cultural variation in sources of stress, as well as resources for coping with stress. In order to test this theory, Parker et al. (2001) studied two sets of depressed patients – Malaysian Chinese and Australian Caucasians. The patients answered questionnaires where they were asked what the primary symptom was that led them to seek help.  The Malaysian Chinese were more likely to report a somatic symptom, while Australian patients were more likely to report mood-related symptoms.

When psychologists assume that psychological disorders are universal and can be diagnosed using a standardized inventory to gather information about the symptoms, this is an etic approach to diagnosis.  When the researchers discuss mental health with local practitioners and adapt their tests in order to meet the cultural needs of a community, this is an emic approach to diagnosis. Such an approach was used by Bolton (2002) who carried out a study in Rwanda to help distinguish between PTSD and normal grief as a response to the genocide. In classifying mental illness – what the Rwandans called Guhahamuka – symptoms included feeling like you have a cloud within yourself, hiding from people and feeling like you are having an epileptic episode.  These are symptoms that would not be included in a standard PTSD inventory.

Socioeconomic considerations in diagnosis

Stressors of all kinds are more likely to affect individuals living in poverty. Research shows that one’s socioeconomic status may influence one’s mental health but also the diagnosis.  One of the earliest studies of its kind was the Midtown Manhattan study (Srole et al, 1961) – a series of over 1000 interviews of individuals in the city. The study found the highest levels of mental illness among the lower class. But based on what we know about the biases that may affect the validity of diagnosis, can we trust the findings of this study?

Johnstone (1989) found that regardless of the symptoms, more serious diagnoses were given to lower-class patients. They were more likely to spend longer periods in hospital and were more likely to be prescribed drug therapy rather than psychotherapy. Health professionals justified this by claiming that working-class people were less able to benefit from verbal therapies because they were less literate. Johnstone concluded that working-class patients, who experienced the most social and economic hardship, did not benefit from therapies that would help them to become more independent and learn to cope with their disorder.

Although there is definitely evidence of bias, there appear to be actual differences in the prevalence of disorders.  As seen in studies of stress, individuals with low socioeconomic status suffer more from both physiological and psychological illnesses.  Several psychologists propose vulnerability models as explanations for mental illness.  Lower classes have less access to protective factors that can help them to maintain positive health.  This will be explored more in the etiologies section of this unit.

Checking for understanding

Ethics in diagnosis