Diagnostic consistency in assessing conduct disorder: an experiment on the effect of social context

Conceptualizing Culturally Infused Engagement and Its Measurement for Ethnic Minority and Immigrant Children and Families

Despite the central role culture plays in racial and ethnic disparities in mental health among ethnic minority and immigrant children and families, existing measures of engagement in mental health services have failed to integrate culturally specific factors that shape these families' engagement with mental health services. To illustrate this gap, the authors systematically review 119 existing instruments that measure the multi-dimensional and developmental process of engagement for ethnic minority and immigrant children and families. The review is anchored in a new integrated conceptualization of engagement, the culturally infused engagement model. The review assesses culturally relevant cognitive, attitudinal, and behavioral mechanisms of engagement from the stages of problem recognition and help seeking to treatment participation that can help illuminate the gaps. Existing measures examined four central domains pertinent to the process of engagement for ethnic minority and immigrant children and families: (a) expressions of mental distress and illness, (b) causal explanations of mental distress and illness, (c) beliefs about mental distress and illness, and (d) beliefs and experiences of seeking help. The findings highlight the variety of tools that are used to measure behavioral and attitudinal dimensions of engagement, showing the limitations of their application for ethnic minority and immigrant children and families. The review proposes directions for promising research methodologies to help intervention scientists and clinicians improve engagement and service delivery and reduce disparities among ethnic minority and immigrant children and families at large, and recommends practical applications for training, program planning, and policymaking.

A Dimensional Comparison of a Self-Report and a Structured Interview Measure of Conduct Disorder

Eligibility for a diagnosis of antisocial personality disorder (ASPD) requires evidence of antecedent conduct disorder (CD). Accurately identifying CD may be influenced by various factors, including assessment methodology. The present study used a two-parameter latent variable model to examine the relative performance of a self-report measure and a structured clinical interview in retrospectively detecting the CD spectrum among adult male offenders (N = 1,159). Self-report and clinical interview tended to converge regarding the rank order of severity indicated by CD symptom criteria. In addition, at relatively low levels of CD severity, self-report provided more information about the CD spectrum than did clinical interview. At relatively higher levels of CD severity, however, clinical interview provided more information about the CD spectrum than did self-report. Latent variable models offer a potential means of combining multiple assessment methods in a way that maximizes information gleaned by capitalizing on the contextual strengths of each approach.

Thinking you can catch mental illness: how beliefs about membership attainment and category structure influence interactions with mental health category members

We explored beliefs about mental disorder categories that influence potential interactions with category members. Specifically, we investigated beliefs related to how membership in a mental disorder category is obtained (communicability and causal origin) as well as beliefs related to the underlying reality of disorder categories (essentialism and controllability). In Experiment 1, participants' interaction-willingness decisions were predicted by their beliefs that a mental disorder category was (1) communicable, (2) psychologically caused, (3) environmentally caused, and (4) possessed all-or-none membership. With fictitious mental disorders, people were less willing to interact with people described as having a communicable mental disorder than with those described as possessing any of the other factors of interest, highlighting the independent influence of these contagion beliefs (Experiment 2). We further explored beliefs about the communicability of mental disorders in Experiment 3 by asking participants to generate descriptions of how mental disorders are transferred between people. Our findings suggest the importance of understanding contagion beliefs in discovering why people distance themselves from people diagnosed with mental disorders. More generally, our findings help in understanding how our basic category knowledge is used to guide interactions with category members, illustrating how knowledge is translated into action.

Diagnosis in the field of psychotherapy: a plea for an alternative to the DSM-5.x

PURPOSE

This paper studies how diagnosis is currently conceptualized in the field of psychiatry, and examines whether this mode of diagnosis is relevant for psychotherapeutic intervention.

METHOD

Narrative literature review was used in this study.

RESULTS

In the context of the DSM, diagnosis is equated with classification. Symptoms and complaints are approached in terms of a medical semiological model, and are seen as signs of underlying illness processes. In discussing this approach the author makes use of Gottlob Frege's theory, in which three aspects of a sign are discerned: the reference/referent or Bedeutung, the sense or Sinn, and the representation/idea or Vorstellung. Based on this distinction, it is argued that in the transition from the DSM-III to the DSM-5 much effort has been taken to disambiguate the sense attributed to symptoms and complaints, while person-specific ideas and representations have been excluded. This exclusion of the Vorstellung is criticized, both from a psychiatric and a psychotherapeutic perspective. Subsequently it is argued that whereas the DSM-III and DSM-IV avoided strong statements on etiology, the DSM-5 makes clear choices. The DSM-5, and more recently the RDoC group within the NIMH, aims at developing systems of classification that start from the assumption that psychiatric disorders are brain disorders. It is argued that by doing so a referent is classified that is different from the object of intervention that psychotherapeutic theories are concerned with.

CONCLUSION

Such a view of diagnosis is not workable for psychotherapy. The exclusion of personal experiences associated with symptoms and complaints is problematic and the referent that recent psychiatric classification uses, that is, brain processes, is not compatible with the referent that psychotherapeutic theories use. Case formulation can be seen as an alternative to standard classification.

Do clinical psychologists extend the bereavement exclusion for major depression to other stressful life events?

BACKGROUND

In assessing potential cases of major depressive disorder (MDD), to what extent do clinicians interpret symptoms within the explanatory context of major life stressors? Past research suggests that when clinicians know a plausible life event cause for a person's disordered symptoms, they generally judge that person to be less abnormal than if the cause was unknown. However, the current, fourth edition of the Diagnostic and Statistical Manual of Mental Disorders specifies that only bereavement-related life events exclude a client from a diagnosis of MDD, and the upcoming fifth edition of the manual (DSM-V) is currently slated to eliminate this bereavement clause altogether.

OBJECTIVE

To systematically examine whether clinicians' judgments reflect agreement with either of these formal DSM specifications.

METHOD

In a controlled experiment, 72 practicing, licensed clinical psychologists made judgments about realistic MDD vignettes that included a bereavement event, stressful non-bereavement event, neutral event, or no event.

RESULTS

Bonferroni-corrected paired comparisons revealed that both bereavement and non-bereavement life events led MDD symptoms to be rated as significantly less indicative of a depression diagnosis, less abnormal, less rare, and less culturally unacceptable (all P ≤ 0.001) relative to control conditions.

LIMITATIONS

Clinicians made judgments of realistic, controlled vignettes rather than patients.

CONCLUSIONS

The results suggest that practicing clinical psychologists assess symptoms within the explanatory context of bereavement and non-bereavement life stressors, indicating a departure from the DSM's recommendations, both current and proposed.

IMPLICATIONS

for diagnostic decision making and the clinical utility of the DSM's recommendations are discussed.

Development and validation of the Conduct Disorder Rating Scale

Several rating scales for measuring externalizing problems in children are inconsistent with widely used diagnostic criteria for conduct disorder (CD). The Conduct Disorder Rating Scale (CDRS) was developed to provide valid measures of CD in children age 5 to 12 years. In Study 1, the CDRS was evaluated in a community sample of 1,554 children. Parents and teachers showed modest agreement in their ratings and children's age and gender differences were consistent with epidemiological trends. In Study 2, the CDRS was evaluated in a clinical sample of 80 children who were assessed for a summer treatment program. The parent version of the CDRS showed 78.8% accuracy in identifying CD against a diagnostic interview, and both parent and teacher versions of the CDRS were significantly associated with observations of antisocial behavior. Although further research with this new tool is warranted, results indicated that the CDRS is well suited to observational and clinical studies of CD.

Judging mental disorder in youths: Effects of client, clinician, and contextual differences

Using a vignette-based, mailed survey of 1,401 experienced psychologists, psychiatrists, and social workers, the authors examined how clients' race/ethnicity and clinicians' professional and social characteristics affect their judgment of mental disorder among antisocially behaving youths. Vignettes described problematic behaviors meeting the Diagnostic and Statistical Manual of Mental Disorders (4th ed.; DSM-IV; American Psychiatric Association, 1994) criteria for conduct disorder but contained contextual information suggesting either disorder or nondisorder, following DSM-IV guidelines. Clinicians depended on contextual information to decide whether a mental disorder existed, and they judged White youths to have a disorder more frequently than Black or Hispanic youths. Clinicians' occupation, theoretical orientation, and age also were associated with disorder judgments, whereas their gender, race, and experience were not. Research and training implications of these variations in clinical judgments are discussed.