Bias In Diagnosis: Gender and Ethnicity

Some have argued that diagnosis may be affected by factors, such as gender, ethnicity and social class. This means that the label attached by the psychiatrist may have been influenced by things other than the symptoms presented.

Ethnicity: The Case of Calvin

Littlewood and Lipsedge (1997) have suggested that the reason why black and Irish people in Britain are more likely than others to receive a diagnosis of serious mental disorder has more to do with bias in the system than a genuine greater vulnerability in those groups. They describe the case of Calvin, a Jamaican man arrested following an argument with the police when a post office clerk believed he was cashing a stolen postal order (an accusation which later proved to be false). The following was recorded by a British prison psychiatrist:

“This man belongs to Rastafarian – a mystical, Jamaican cult, the members of which think they are God-like. The man has ringlet hair, a straggly goatee beard and a type of turban. He appears very eccentric in his appearance and very vague in answering questions. He is an irritable character and has got arrogant behaviour.”

The aforementioned shows the ignorance within psychiatry; the suggestion is that anyone who appears different MUST have something wrong with them.

Fernando (1992) also provides an insight into diagnosis and bias:

– Over-diagnosis of schizophrenia among West Indian and Asian British. This means for the same symptoms, disproportionately more individuals from these groups were diagnosed as schizophrenic rather than any other illness.

– Excessive admission of ‘offender patients’ among West Indian British. Individuals in this group were more likely to be put into prison than in hospital.

– Excessive use of compulsory admission for West Indian British. Research in South London found that Black patients were three times more likely to be institutionalised than Whites.

It is important to emphasise that the differences are not due to differences in the prevalence of mental illness among the ethnic groups – it is a product of the bias in the mental health system.

Gender:

Similarly, this argument links to the second type of bias in the mental health system – women. Lloyd (1991) noted that women made up 4% of the prison population, but 20% of the population of the Special Psychiatric Hospitals. Women who are aggressive, addicts or living rough are more likely to be diagnosed as anti-social personality disorder than men in the same situation.

Culture-Bound Syndromes

Culture-bound syndromes are mental health problems with a set of symptoms found and recognised as an illness in a particular culture. They are deemed to be ‘folk illnesses’, which can be treated by ‘folk medicines’.

Many psychiatrists reject the idea of culture-bound syndromes. However, the most commonly recognised ones are now listed in the DSM-IV, showing some signs of improvement.

An example of a culture-bound syndrome:

“One of the best known culture-bound syndromes is ‘amok‘. Typically, a person who ‘runs amok’ will have suffered from public insult, some severe loss or shame. He will become quiet and pressed for a while and then suddenly seize a dangerous weapon (i.e. an axe, sword, gun), run into a public place and start killing people.

A similar phenomenon has been reported from Papua New Guinea, the Philippines, Laos, Puerto Rico and among the Native American Navajo.

Amok is a culture-bound syndrome because its occurrence is particularly frequent in certain countries, and takes a recognisable form. The DSM-IV describes this as an impulse control disorder called Intermittent Explosive Disorder. This diagnosis is given to people who lose control of aggressive impulses. unpredictably, on repeated occasions. ”

Culture-bound syndromes can have serious implications on diagnosis, as they do not fit into the DSM.

Sources:

– Brain, C. (2009). Edexcel A2 psychology. London: Philip Allan

– http://www.health24.com/mental-health/disorders/amok-20120721

Evaluation Of Rosenhan’s ‘Sane In Insane Places’ (1973)

Strengths:

– The investigation was carried out in hospitals with staff who were unaware of the experiment. Therefore, the study could be said to have high ecological validity.

– The hospitals used were varied (old and new, private and public), allowing for generalisation. This is further supported through the use of the twelve hospitals which were involved in the study.

– The pseudo-patients admitted themselves under a different name, meaning that their identities were protected. Ethically-speaking, this is a strength, as the individuals do not need to associate themselves with the label that was attached to them as a result of being admitted.

– Participant Observation – the pseudo-patients were able to experience the ward from a patient’s perspective, whilst also maintaining some degree of objectivity.

– Doctors are likely to err on the side of caution, meaning that they are more likely to admit a patient who is ‘healthy’ if they are not sure – the ‘better to be safe than sorry’ principle.

Weaknesses:

– The hospital staff and patients were deceived. They did not have the decision to withdraw from the experiment or give their consent. Therefore, the study could be seen to be unethical.

– Rosenhan may have been too hard on psychiatric hospitals as the pseudo-patients were simulating symptoms of schizophrenia. They were merely following the guidelines of the DSM.

– An older classification was used – at the time, DSM-II was in use. The introduction on the DSM-III in 1980’s helped to eliminate unreliability. This meant that psychiatrists were less likely to make errors.

Criticisms:

Validity:

– Seymour Ketty (1974) criticised Rosenhan’s deception from a validity perspective, saying: “If I were to drink a quart of blood and, concealing what I had done, had come to the emergency room of any hospital vomiting blood, the behaviour of the staff would be quite predictable.” Ketty’s point was that psychiatrists will hardly expect someone to carry out deception in order to be admitted to a psychiatric hospital.

Reliability:

– Robert Spitzer (1976) notes that the diagnosis, ‘Schizophrenia-in-Remission’, is extremely rare. He examined the records of 12 other American hospitals and found that in 11 cases, ‘S-I-R’ was either never used or used only for a handful of patients each year. Therefore, Spitzer claims that psychiatrists’ discharge diagnosis was due to how the pseudo-patients behaved, not because they couldn’t tell they were normal.

Rosenhan (1973) – ‘Sane In Insane Places’

Image: http://40.media.tumblr.com/e89c282c970f0ba57f502b976f1cb7c2/tumblr_n4tqmk4Ikp1rt6iypo1_500.jpg]

There is a long history of attempting to understand and classify abnormal behaviour. As has been previously stated, there is a lot of difficulty defining abnormality. In the 1960’s, a number of psychiatrists decided to come together and fiercely criticise the medical approach to abnormality. From this, the Anti-Psychiatry Movement was born. R.D. Laing and Rosenhan were supporters of this movement.

As a result of the Anti-Psychiatry Movement, Rosenhan set out to demonstrate just how unreliable psychiatric classification can be. He argued that ‘psychiatric diagnoses’ were in the mind of the observers. This led to his study, ‘Sane In Insane Places’.

Aim: To investigate whether psychiatrists were able to distinguish between people who are perceived to be ‘sane’ and those who are labelled as ‘insane’.

Procedure:

– The experiment itself was a field experiment.

– The Independent Variable (IV) was the symptoms of the patients.

– The Dependent Variable (DV) was the psychiatrics’ admission and diagnostic label of the ‘patient’

– It was a participant observation.

Eight patients (consisting of five men and three women) tried to gain admittance to 12 different hospitals in five different states in the USA. The following were comprised on a psychology student, three psychologists, a paediatrician, a psychiatrist, a painter, and a housewife. This included Rosenhan himself.

These pseudo-patients telephoned the hospital for an appointment, and arrived at the admissions office complaining they had been hearing voices. They said the voice, which was unclear and the same sex as themselves, said ‘hollow’, ‘thud’ and ’empty’. These symptoms were partly chosen as concerns arise about the meanings of the individual’s life.

After they had been admitted to the psychiatric ward, the pseudo-patients stopped simulating symptoms of abnormality. They then told staff they were fine and no longer experience symptoms.

Results:

None of the pseudo-patients were detected, and were all (bar one) admitted with a diagnosis of schizophrenia and were eventually discharged bearing the label ‘schizophrenia in remission’. They remained in hospital for 7 to 52 days (an average of 19 days each). Although they were not detected by staff, many of the patients suspected they were ‘sane’.

The pseudo-patients’ normal behaviours were often seen as aspects of their supposed illness. For example, nursing records for three of the pseudo-patients showed that their witing was seen as an aspect of their pathological behaviour. Rosenhan notes that their is enormous overlap in the behaviours of the ‘sane’ and the ‘insane’.

Psychiatrists and nurses made little contact with the patients, according to the participants. Powerlessness and depersonalisation were also experienced. It was estimated that the pseudo-patients were given a total of 2,100 tablets, though only two were swallowed.

There was a follow-up study conducted after this initial experiment by Rosenhan himself:

Rosenhan informed staff at a teaching hospital that sometime in the next three months, one or more pseudo-patients would attempt to be admitted. Each staff member was asked to rate patients presenting themselves on a scale of 1 to 10 to reflect the likelihood of them being the pseudo-patient.

Judgements were given on 193 patients admitted for psychiatric treatment. 41 were judged with high confidence by at least one staff member to be pseudo-patients, 23 were considered suspect by at least one psychiatrist, and 19 were thought to be pseudo-patients by one psychiatrist and another staff member. There were actually no genuine pseudo-patients involved in this study.

The conclusions that Rosenhan drew from both studies gave insight into the world of psychiatry and diagnosis. His argument was that individuals are not insane all of the time but, once a person is labelled ‘insane’, all their behaviour is understood through that label.

Sources:

– Brain, C. (2009). Edexcel A2 psychology. London: Philip Allan

The DSM

The Diagnostic and Statistical Manual of Mental Disorders, or the DSM, is a piece of text published by the American Psychiatric Association, which provides criteria from which mental disorder can be diagnosed. First published in 1952, the DSM has had over five revisions. The most recent edition is the DSM-V.

The DSM system was developed in response to the need for a census of mental health disorders.

This guide is based on five axis:

Axis 1: Considers clinical disorders, major mental disorders, developmental disorders and learning disorders. An example of the disorders found includes schizophrenia.

Axis 2: Looks at underlying personality conditions, including mental retardation. An example of the disorders found in this axis include obsessive-compulsive disorder.

Axis 3: Considers general medical conditions, as the symptoms of some medical disorders are similar to mental disorders. An example of this would be hypothyroidism (an underactive thyroid), which mimics the symptoms of depression (i.e. fatigue).

Axis 4: Looks at psychosocial and environmental problems, which may have an effect on the disorder. An example of this would be issues within the family. This may contribute to the disorder.

Axis 5: The Global Assessment of Functioning (GAF) scale, which ranges from 0 to 100. The psychiatrist has to assess how able the patient is to cope with everyday life, and so how urgent their treatment is. Someone with a high score (i.e. 100) is said to be functioning perfectly, whereas an individual with a low score (i.e. 30) is said to have serious problems in several areas of their life.

Example of diagnosis from Davidson and Neale (1994):

“Alex was assessed after having been arrested for sexually assaulting a woman when he was drunk. He had been almost continually drunk for the past four years, since his daughter was killed in a accident. He now has liver damage. It was also found that he had a history of gang violence and domestic violence. He showed no remorse about any of his actions.”

Axis 1: Alcohol Dependence

Axis 2: Anti-Social Personality Disorder

Axis 3: Liver Damage

Axis 4: Arrest, Death of his child

Axis 5: 42

You may also need to be aware of the International Statistical Classification of Diseases and Related Health Problems (ICD), which is used more often than the DSM in some parts of the world.

Sources:

– Brain, C. (2009). Edexcel A2 psychology. London: Edexcel

– Brain, C. (2009). Edexcel A2 psychology. London: Philip Allan