Reliability and Validity of the Diagnosis of Psychosis throughout History: Analytical Essay

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Claim:

Diagnosis is always right

Rationale:

Diagnosis is defined as the identification of disease or illness through the examination of universal signs or symptoms one may exhibit (Susman, 2018). The diagnosis of mental disorders by psychiatrists is guided by a universal classification book known as the DSM-5 which is the Diagnostic and Statistical Manual of Mental Disorders (American Psychiatric Association, 2019). The concepts of validity and reliability are essential to the process of diagnosis. Diagnosis that lacks both validity and reliability contradicts the claim that‘ diagnosis is always right.’

The validity of diagnosis refers to how accurate the criteria used to define a disorder is in describing the disorder it is intending to describe. The concept of diagnosis in regard to psychological disorders has always been a controversial topic of discussion. This is due to the quite common instances of misdiagnosis that continue to occur today (Susman, 2018). Regardless of the many medical advances that have been made recent years, misdiagnosis is still a very real possibility and concern for many patients.

Reliability refers to whether two professionals are able to come to the same conclusion using the same classification method (Crane, 2019). In fact, a study conducted by Sandifer et al (1964) revealed that the possibility of two psychiatrists agreeing on the same diagnosis was only 57%. This validates the concern that lies within the reliability and validity of the diagnosis of psychological disorders.

This investigation will be narrowed down to specifically address the diagnosis of psychosis, a mental disorder that characterised by an inability to interpret and distinguish the real world (ReachOut Australia, 2019). The reliability and validity of the diagnosis of psychosis throughout history will be investigated in order to address the claim that‘ diagnosis is always right.’

Research Question:

This investigation is to address the following research question:

To what extent is psychosis a disorder that cannot be universally categorized, therefore compromising the validity and reliability of its diagnosis.

Evidence:

David Rosenhan was an American Psychologist who found interest in challenging the classification system that was the DSM-II. In 1973, he conducted an experiment with the objective of testing whether psychiatrists were reliable in differentiating the sane from the insane (Rosenhan, 1973). Rosenhan’s experiment involved seeing whether pseudo patients who were pretending to exhibit the symptoms of schizophrenia would get admitted into a psychiatric facility. To conduct this, Rosenhan used a sample size of 8 people all of different ages, professions, and genders and asked them to exhibit the same existential symptoms including hearing voices that questioned their existence to professionals at a hospital. However, each patient was truthful in every other aspect of this meeting with the health professional with the only exception being that their identity was concealed (Rosenhan, 1973).

All of the pseudo patients were admitted into psychiatric facilities with a diagnosis of schizophrenia except one who was diagnosed with manic-depressive psychosis and spent a total of 7-52 days in the facility. This does not support the claim that diagnosis is always right as it presents a clear example of psychiatrists incorrectly diagnosing individuals thus, questioning the validity and reliability of diagnosis. However, a limitation of this study is the fact that it was based on the deception of health professionals, not only is this unethical but it also compromises the results of the study as it in no way indicates that other patients in the facility had the same experience or were misdiagnosed. Another limitation of this experiment is that it was conducted in 1973 so, although Rosenhan’s experiment provides basis to question the validity and reliability of diagnosis, the methodology is too narrow to make a generalization.

Since Rosenhan’s experiment was conducted, the classification method of the diagnosis of psychological disorders was updated to the DSM-III and was changed several times after that. This would have impacted the validity and reliability of diagnosis as there have been many cases since in which patients had been correctly diagnosed with psychosis and recovered due to this correct diagnosis. The DSM-IV is a classification method that was adopted years after Rosenhan’s experiment with the objective of improving the reliability and validity of diagnosis. For example, Jessica was a young university student who was once extremely social and outgoing however this all changed when she became increasingly paranoid that her friends were watching her all the time even when she was home along (Corbett, 2007). Among explaining this and other events to a psychiatrist, Jessica was diagnosed with psychosis.

Upon being diagnosed with psychosis, Jessica engaged in a mixture of psychotherapy which involved her meeting with a psychologist and talking about her illness, ways to prevent relapses, and healthy life choices, and pharmacotherapy which involved her taking medicine to reduce the symptoms of psychosis (Corbett, 2007.) As a result of this treatment, Jessica was able to manage the disorder and return to university to complete her degree (Corbett, 2017.) Jessica’s story supports the claim that‘ diagnosis is always right.’ However, a limitation of this case study is the fact that it is based on the experience of 1 individual. Although many others can relate to Jessica’s story, it can not be used to generalize everyone who has been diagnosed with psychosis.

Although cases like Jessica’s are very common, there are still many cases in which the validity of diagnosis has provided room for questioning. In 2002, Kim and Ahn conducted a study to assess the validity of diagnosis. Kim and Ahn (2002) suggested that psychiatrists analyze symptoms that are related to a theory and make diagnosis based on that theory as opposed to a structured criteria list like what was being provided in the DSM-IV (Blashfield, 2014). In this study, professionals’ theories of a disorder and their response to memory and diagnostic tasks was measured. The results of this study revealed that professionals were likely to diagnose someone with a disorder if their symptoms aligned with the theory that they associated with the disorder (Blashfield, 2014). This contradicts the validity of the DSM-IV as an adequate classification method for disorders like psychosis as it is not designed to suit the diagnosing process of psychiatrists. However, a limitation of this study is that it was conducted in 2002 and since then the classification method has been updated to the DSM-5 (2013.)

However, there are real-life cases that also contradict the claim ‘diagnosis is always right,’ and discredit the validity and reliability of the diagnosis of psychosis. An example of this is a 42-year-old woman who was wrongly diagnosed with psychosis and schizoaffective disorder (Shah, 2018). The woman went to hospital to examine abnormal behavior that she was exhibiting including a speaking to herself, verbally abusing others, and wandering aimlessly (Shah, 2018).

Upon this diagnosis, the patient was prescribed with medication for psychosis and schizoaffective disorder however, many of the symptoms persisted regardless of the medication. Upon revaluation, the same diagnosis was concluded and she was simply instructed to switch from one medication to another. It was after an extensive 3 years of misdiagnosis that the patient was finally diagnosed with Wilson’s disease, a rare disorder that causes copper poisoning, by an ophthalmologist. A limitation of this study is that it only invalidates a specific psychiatrist, this experience is not shared by every person who suffers and is diagnosed with Wilson’s disease. Therefore this case cannot be used to make a generalization.

Conclusion:

The results of Rosenhan’s study (1973) corroborate with Kim and Ahn’s study (2002) and is also supported by the case of the woman who was wrongly diagnosed with psychosis (Shah, 2018). All of these studies exposed flaws within the validity and reliability of the classification of mental disorders, specifically in regard to psychosis. However, Jessica’s story provides evidence that is in supports of the fact that the classification method for diagnosing psychosis is valid and reliable due to Jessica’s successful treatment (Corbett 2007). Ultimately, various limitations in the evidence suggest that more extensive investigations and studies of classification methods in regard to reliability and validity are essential before a conclusion can be drawn.

Therefore, the evidence provided in this investigation is not in an adequate position to make a conclusion in regard to the research question ‘to what extent is psychosis a disorder that cannot be universally categorized, therefore compromising the validity and reliability of its diagnosis.

This investigation can conclude that there are various cases in which disorders have been correctly diagnosed using the appropriate classification system and treated according to. However, the existence of studies and cases in which diagnosis has lacked validity and reliability means that the claim ‘diagnosis is always right’ cannot be supported.

Evaluation:

There are various flaws within the evidence provided that compromise its quality and would require improvements for this evidence to be considered credible and for the claim ‘diagnosis is always right to be investigated.

A limitation that is common in Rosenhan’s experiment and in Jessica’s case is the absence of any data relating to the interrater reliability of the diagnosis. Inter-rater reliability refers to whether different professionals are able to agree on the same diagnosis (Lange, 2019). In both of these examples, it is not disclosed whether the wrong diagnosis was administered by one psychiatrist or was corroborated by many.

An improvement that would not only make diagnosis more reliable but also increase the validity would be to make it mandatory for psychiatrists to confirm their diagnosis with other psychiatrists and even doctors of a range of medical fields.

Another limitation in this evidence is the lack of ecological validity within Rosenhan’s study (1973). Ecological validity refers to whether the results of a study can be generalized to represent the population (Gouvier, 2019). Rosenhan’s experiment lacks ecological validity because the students he used for the study were pretending to have a mental disorder that they did not, therefore this study does not reveal information about how actual patients with psychosis are diagnosed. Also, Rosenhan’s study only consisted of 8 pseudo patients so even if the other flaws in the methodology were disregarded, the sample size is still way to small and non-representative of the population to be used to make a generalization. An extension to improve the ecological validity of this study would be to increase the sample size and reframe the methodology to remove the use of pseudo patients.

Furthermore, in the annual review of clinical psychology by Blashfeild et al (2014), it is stated that the most current classification method, the DSM-5 was only released in 2013. As a result of this, there is yet to be any research done in support of the validity and reliability of this classification (Blashfeild, 2014). This is definitely a limitation of this investigation as the reliability and validity of the diagnosis of psychosis cannot be assessed in a modern context due to the lack of evidence on the new classification system.

It can be concluded by the evidence compiled in this investigation that there are many cases in which diagnosis of psychosis has lacked complete and total reliability and validity, as a result, at this point the claim ‘diagnosis is always right cannot be fully supported. However, the limitations in this evidence and weaknesses in the methodology prevent the findings from this investigation from being used to generalize to the diagnosis of all mental disorders.

References

American Psychiatric Association. (2019). Diagnostic and Statistical Manual of Mental Disorders. Retrieved from American Psychiatric Association: https://www.psychiatry.org/psychiatrists/practice/dsm
Blashfield, R. (2014). The cycle of classification: DSM-I through DSM-5. Retrieved from US National Library of Medicine: https://www.ncbi.nlm.nih.gov/pubmed/24679178
Corbett, R. (2007). Recovery From Psychosis Is Expected. Retrieved from Here to Help: https://www.heretohelp.bc.ca/visions/campuses-vol4/recovery-from-psychosis-is-expected
Crane, J. (2019). Validity and reliability. Retrieved from IB Psychology: https://www.thinkib.net/psychology/page/22454/validity-and-reliability
Gouvier, W. (2019). Ecological validity. Retrieved from Encyclopedia Britannica: https://www.britannica.com/science/ecological-validity
Lange, R. (2019). Inter-rater Reliability. Retrieved from Encyclopedia of Clinical Neuropsychology: https://link.springer.com/referenceworkentry/10.1007%2F978-0-387-79948-3_1203
ReachOut Australia. (2019). What is psychosis? Retrieved from ReachOut Australia: https://au.reachout.com/articles/what-is-psychosis
Rosenhan, D. (1973). On being sane in insane places. Retrieved from US National Library of Medicine National Institutes of Health: https://www.ncbi.nlm.nih.gov/pubmed/4683124
Shah, B. (2018). A Case Report of Misdiagnosis of Psychotic Symptoms Predominant Wilson’s Disease. Retrieved from US National Library of Medicine: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6126283/
Susman, D. (2018, April 17). How Do You Diagnose a Mental Illness? Retrieved from Psychology Today : https://www.psychologytoday.com/au/blog/the-recovery-coach/201804/how-do-you-diagnose-mental-illness

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