Sunday, 5 February 2017

UNI ESSAYS Compare and contrast categorical and dimensional approaches to diagnosing mental health conditions.

Mental health conditions can be a huge problem if not diagnosed correctly or at all. A patient with a mental health issues may suffer distress or disability beyond what may be considered normal to a person’s development or culture.

According to a bulletin published in 2000 by the World Health Organisation, over a third of people in most countries report problems at some time in their life which meet criteria for diagnosis of one or more of the common types of mental health conditions.

The current system used for categorical diagnoses of mental health conditions is the Diagnostic and Statistical Manual of Mental Disorders (DSM). The DSM was first published in 1952 and has since undergone 5 revisions to its current state which was published in 1994 (with a text revision in 2000). The current manual is DSM-IV-TR, with an update due in 2013. The manual was created from a system collecting statistics in a psychiatric hospital and a manual developed by the United States Army. 

Before the introduction of the DSM, mental disorders were diagnosed using the International Classification of Diseases (ICD) which was only introduced in 1939. Before this, mental health conditions were put down to "supernatural" causes such as demonic possession. Unfortunately for sufferers, treatment was often barbaric and almost always lead to the death of the patient.

The manual uses a categorical classification system to determine whether or not a patient suffers a mental health condition. The current manual uses a multi-axial classification system which comprises of 5 axes:

Axis I contains the diagnostic criteria for major mental health conditions, learning disorders and substance use disorders including depression, anxiety, the autistic spectrum, eating disorders and schizophrenia. 

Axis II contains the diagnostic criteria for personality disorders and intellectual disabilities such as paranoid personality disorder, borderline personality disorder, obsessive compulsive disorder and narcissistic personality disorder amongst others. 
Axis III contains the diagnostic criteria for acute medical conditions and physical disorders such as brain injuries and any other physical impairment which may exacerbate an existing disease. 

Axis IV identifies psychosocial and environmental contributors to disorders 

Axis V contains the global assessment of functioning for children and teens under the age of 18. This assessment gives a score on a scale of 1 to 100 to measure the severity of a given disorder.  A diagnosis will be made based on the information provided to a mental health professional by the patient.

The categorical approach is strong in that it helps to find similarities in within categories to help ongoing treatment of the patient. A mental health professional can use the same techniques to diagnose and treat many patients with similar symptoms. However, the categorical approach does not allow for an overlap. A patient either has one disorder or another. This makes diagnosis difficult as the disorders listed in the manual can have overlapping symptoms.

Helmuth (2003) states that a patient could present with symptoms across multiple disorders however without the allowance for an overlap the patient will be placed into a category with the most amount of symptoms. This could easily lead to a misdiagnosis. Helmuth also states that a patient may be misdiagnosed due to the severity of symptoms. If a symptom is not as severe as is required by the DSM then that symptom will not be counted towards the diagnosis and this can be very problematic.

 Another issue with the categorical approach is the assignment of a label to a patient. Once a patient is diagnosed with a specific disorder and a label applied, it can be very difficult for that label to be removed. Rosenhan (1973) suggests that these patients would have a ‘sticky label’ from their diagnosis suggesting that even if the diagnosis is removed there will still be some residue much like that of a sticking plaster. This residue can be difficult to remove and may have a profound effect on the patient in terms of stigma.

Another approach used for diagnosing mental health conditions is the dimensional approach.  The dimensional approach uses a scoring system to diagnose patients. This would mean that rather than being diagnosed with a specific disorder the patient will be placed on a sliding scale relative to how a disorder affects their day to day life.

The dimensional approach, allows for ‘co morbidity’ which is the existence of one or more mental health condition in addition to the primary condition. With the patient being placed on a continuum it is easy for the mental health professional to monitor the progression and intensity of a disorder which may fluctuate due to many life circumstances. This would avoid the issue of labelling as the patient is on a sliding scale. The problem with the dimensional approach is that it relies upon a notion of separate and distinct mental mental health condition (Wittenhall 2007). However, it does not attach the same amount of stigma as a categorical classification.

Many sufferers of mental health conditions will go for years, or even their entire life, without a diagnosis in order to avoid a social stigma. Mental health problems are not portrayed in a particularly favourable light within the world media, therefore it is understandable for a person to be unwilling to seek a diagnosis. The stigma of mental health issues not only affects the person suffering but also the people in their immediate surroundings. This was found in a study by Östman and Kjellin in 2002. Being stigmatized can not only affect the patient and their family but may also cause further symptoms leading to a misdiagnosis which would cause the patient further stress and result in the patient not being treated correctly.

It would appear that the dimensional approach presents with the least amount of problems for the patient. The newer revision of the DSM will make allowances for co morbidity and make diagnoses much easier and treatment much more effective for the individual suffering the disorder rather than the disorder itself.

Helmuth, L. (2002). In Sickness or in Beauty? Science. 302 (5646). 808-810.
Östman, M. & Kjellin, L. (2002). Stigma Through Association. British Journal of Psychiatry. 181. 494-498.
Rosenhan, D.L. (1973). On Being Sane in Insane places. Science. 179 (4070). 250-258.
Wittenhall, J (2007)  Eye on Psi Chi Vol. 11, No. 2, pp. 16-17
WHO International Consortium in Psychiatric Epidemiology (2000) Cross national comparisons of the prevalences and correlates of mental disorders Bulletin of the World Health Organisation v. 78 n. 4

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