Introduction
The Diagnostic and Statistical Manual of Mental Disorders creation, and the more widespread knowledge about mental illness meant that more people were diagnosed with a mental illness (The DSM, 1952 – 2013). A mental illness is a condition which causes serious disorder in an individual’s behaviour and thinking. Even though many people are diagnosed with a mental illness we do not know how appropriate that diagnosis is. I am going to look into different aspects of the process of diagnosing a mental illness and how this influences behaviour. Outside of the DSM I will look at abnormal psychology. In this study they look into unusual emotions, patterns of behaviour, and, thoughts which could be a mental illness. The reliability of labelling someone with a mental illness depends whether psychiatrists can distinguish between “normal” people and actual “mentally ill” people. I am also going to research what a mental illness and the self fulfilling prophecy does to you, which states you will act according to your mental illness. I will also research how a diagnosis of mental illness helps you. My research question is: to what extent is it appropriate to label an individual with a diagnosis of mental illness. It is important to study this topic because we should have an understanding of the impact of labelling an individual with a diagnosis of mental illness. Mental illness is an important topic in the 21st Century and we should know how to help individuals with their illness without bringing them more harm.
Diagnosis
The process of diagnosing is very important. When not following the right process or diagnosing an individual wrongly there can be big consequences for the individual. It can influence someone’s life.
Abnormality is a part of psychology specifically looking into mental illness. It studies people that are “abnormal” compared to other members of society. Abnormal psychology studies unusual patterns of behaviour, emotion and thoughts which may be a mental disorder. There are various ways to measure abnormality, and Jahoda (1958) suggested various criteria to be classified as normal:
“Positive view of the self”; meaning you look with a positive way towards yourself and are not negative.
“Capability for growth and development”; which is the ability to be able to develop by for example making mistakes.
“Autonomy and independence”; which means you can perform well being independent and do not have to be dependent on others.
“Resistance to stress”; defines that someone should be able to cope with stressful situations.
“Accurate perception of reality”; this criteria focuses on how an individual sees the world. This should be similar to how other people see the world.
“Positive friendships and relationships”; is concerned with whether you have positive friendships and relations.
“Environmental mastery”; is being able to meet the varying demands of day-to-day situations. (Jahoda 1958:22-80)
When fitting into all these criteria you are classified as normal. When you do not fit into these criteria you would be classified as abnormal, and thus probably having a mental illness. This criteria list of being normal has strengths and weaknesses. When an individual for example is struggling with acting normal they can use this list to understand normal behaviour. So when a person knows they have a mental illness, and are classified as abnormal, they would be able to use the list to be more accepted in the society. Moreover, it can help an individual to realise they might have a mental illness which will lead to them seeking for help. However when we look at the list we can see it is impossible to achieve ideal mental health. Because of this it would mean almost the whole population would be abnormal when using this definition. The list also only fits into Western cultures, it is not a global definition. Therefore we cannot relate the theory to other cultures because what we might define as abnormal behaviour is for a different culture defined as normal behaviour. The impact of these weaknesses are that Jahoda’s criteria list is vague and therefore very difficult to measure. This makes it hard to make the decision whether someone is abnormal when not having the criterias of this list. From this we could state that it is not appropriate to label someone with a diagnosis of mental illness as some of the processes are not reliable.
One other way of defining abnormality is statistical infrequency. This definition looks into the mathematical side of defining abnormality. By looking from a mathematical side there is less bias which means there is a smaller chance of a wrong diagnosis. With statistical infrequency a person’s traits are classified as abnormal when it is statistically unusual. It uses standard deviation, when the behaviour falls in the bottom or top 2,5% of the standard deviation it is classed as abnormal. For example when you have an IQ way below or way above the average IQ you are abnormal. Statistical infrequency is mathematical based which means it is clear what abnormal is and there is no bias in the diagnosis because there is no opinion involved. This would mean it is possible to use it cross-cultural. It is also clearly stated when something is abnormal: when it does not occur often. There is no room for an other diagnosis. (Haralambos and Rice, 2000)
A problem with statistical infrequency is some behaviours/characteristics are regarded as abnormal even though they are quite frequent. For example when we look at depression. This is something that happens frequently; about 27% of some population groups suffer from depression. Even though 27% of some population suffers from it it would not be classified as a common problem and it is not normal to be depressed. From these problems we can see that even though there is less room for bias statistical infrequency is not an appropriate way to label an individual with a diagnosis of mental illness as a mental illness that is seen frequently is not classified as mental illness according to statistical infrequency.
One of the methods of labeling someone with a mental illness can be found when we look at the DSM, The Diagnostic and Statistical Manual of Mental Disorders, the handbook is used by healthcare professionals, mostly in the United States but also in other places of the world as a guide to diagnose someone with a mental illness. Because it is used by many psychiatrists diagnosis should be universal. The DSM contains descriptions, symptoms, and other criteria for diagnosing a mental disorder. It is a common language used by clinicians to communicate about their patients and diagnose them in a reliable way. Since first published the DSM has been revised various time because researchers found new mental illnesses. As previous mentioned before the DSM gives a broad explanation of various mental illnesses leaving no room for a misdiagnosis. Because the mental illnesses are explained so precisely it is hard to misdiagnose a patient. It also makes use of the five axis, thus looking at other factors outside of symptoms. (The DSM, 1952 – 2013)
A problem with the DSM can be found when looking at concurrent validity. Even though every psychiatrist uses the same book and explanations it could be that they interpret the explanations differently. When taking two psychiatrists and letting them do tests on an individual their results could come out differently because they interpret symptoms and the DSM differently. This can be seen in the Us-UK diagnostic Project by Cooper et al (1972, 80-102). He aimed to investigate the reliability of a diagnosis of schizophrenia and depression where he used British and American psychiatrist to diagnose individuals with the DSM II from clinical interviews that were taped. It was found that the British psychiatrist diagnosed the individuals twice more often with depression where the American psychiatrist diagnosed them twice as often with schizophrenia. This showed that the same cases did not results in the same diagnosis in different cultures and thus concurrent validity is low. The impact of this problem can be found when we look at how the DSM is used. One psychiatrist could be quicker with diagnosing a patient than the other psychiatrist. The DSM is all on psychiatrist own interpretations and there is no consistent way they can measure the mental illness in a patient. There could be a bias in the diagnosis and a wrong diagnosis would be more likely to happen. From this we could state that when using the DSM it is not appropriate to label an individual with a diagnosis of mental illness as there are different interpretations of symptoms which could lead to wrong diagnosis.
A study investigating the difference between being mentally ill and being sane was conducted by Rosenhan (1973). He did an experiment looking into the validity of diagnosing an individual with a mental illness.
He aimed to test the reliability and validity of a diagnosis in a natural setting. He wanted to know whether psychiatrists could distinguish between actually mentally ill people and “sane” people. He used 8 participants, 5 male and 3 female, who had to get into a hospital’s psychiatric ward. Participants called the hospital, each a different one in the USA, for a diagnosis appointment. They all used fake names and jobs for ethical reasons. The participants were claiming they heard voices in their heads. After the participants were admitted to the psychiatric ward, they stopped showing and talking about the symptoms and acted like they would in normal life. They made notes about their life in the Psychiatric ward and the way they were treated there. The participants asked the staff for favours that tested the behaviour of staff towards patients. For example ‘Could you tell me when I will be presented at the staff meeting?’ or ‘When am I likely to be discharged?’ The results were that all the participants disliked their environment and wanted to be discharged immediately. All the participants were “diagnosed” with schizophrenia when admitted to the hospital and no staff suspected their sanity. The participants were deprived of almost all human rights and privacy and their medical records were not kept confidential. The hygiene in the wards were poor and the Warden would be brutal to patients when no other warden was around which shows patients had no credibility. The notes the participant took during their stay were interpreted as a symptom of their schizophrenia. When they were released they were given the diagnosis schizophrenia in remission. As a follow-up study the staff of one psychiatric hospital were told that impostors would present themselves at the hospital and that they should try rate each patient. Of the 193 patients, 41 were clearly identified as impostors by at least one member of staff, 23 were suspected to be impostors by one psychiatrist and 19 were suspected by one psychiatrist and a staff member. In the group of patients there were no impostors.
Rosenhan concluded that there is an overlap in the behaviour of the sane and the insane. In normal life we all feel depressed once in awhile, have mood swings and are angry but in the psychiatric ward these experiences and behaviours were seen as a sign of a mental illness. (Rosenhan 1973, 237-256)
A problem with Rosenhan’s study is seen in the ecological validity of the method. When psychiatrist are asked to diagnose someone with a mental illness it is expected that the person has some sort of disorder. It cannot be linked to a real life situation since the participants deceived the doctors in faking a mental illness. Naturally the doctor looked for the mental illness. Because the psychiatrist were deceived we do not know how they would react with a real life situation and how the psychiatrist would diagnose that patient. We also do not know if the real patients feel like they are being helped. The impact of this problem can be found when looking at the conclusion, there is an overlap in the behaviour of the sane and the insane. In normal life we all feel depressed once in awhile, have mood swings and are angry but in the psychiatric ward these experiences and behaviours were seen as a sign of a mental illness, because we cannot know what happens with a real life patient who is not pretending to be ill.
This study shows us how a patient gets labelled and how reliable this is. The used participants all received a label of being schizophrenic. If they had gone into the ward under their legal name that diagnosis would have followed them for the rest of their life. It shows how labelling someone with a diagnosis can be invalid and can ruin someone’s life when an invalid diagnosis happens.
Culture
A diagnosis of a mental illness will not always fit every individual, this can lead to wrong treatment. Mental illness can be different across cultures and it is not always appropriate to give the same diagnosis of mental illness to someone from a different culture as different cultures have different rules in society. Fernando (1988) claims that British psychiatry inherited stereotyped ideas about race. We can see this for example in black stereotyping, how it is believed that black people cannot use help and are therefore not suitable for open hospitals. We can see these stereotypes towards black or ethnic minorities happening in England since they are more often diagnosed with schizophrenia and, admitted as offender patients. (Fernando, Ndegwa and Wilson, 1988:51-66)
A study showing these Cultural biases was conducted by Littlewood & Lipsedge (1988). They aimed to investigate whether Black and Irish people in the UK are significantly more likely than other ethnics groups to receive a diagnosis of schizophrenia. They did a case study on ‘Calvin’ a Jamaican man who was arrested due to an argument with the police. There were psychiatry reports uncovered that read:
“The man belongs to Rastafarian – a mystical Jamaican cult, the member of which they think they are God-like. The mas has ringlet hair, a scraggly goatee beard and a type of turban. He appears eccentric in his appearance and is very vague answering questions. He is an irritable character and has got arrogant behaviour.
‘Calvin’ was diagnosed with Schizophrenia, but this diagnosis had more to do with a bias in the system than a genuine diagnosis. They concluded that this bias may result from failure to understand certain behaviours from other cultures.” (Littlewood and Lipsedge, 1988)
However a limitation to this study is the generalisability of the method. They only conducted the study on one participant with one situation. This leads to uncertainty of the results since we do not know what would happen with other culture or different situations. The impact of this limitation can be found when looking at the conclusion because we cannot be sure if there actually was a failure of understanding a different culture.
Culture bound syndrome is a combination of psychiatric and somatic symptoms that are considered to be a recognisable disease only in a specific culture. An important example of culture bound syndrome is Brain fag syndrome. In 1960 Raymond Prince published a paper described unique cultural observation in Nigeria. He described in the paper a cluster of symptoms he observed in Nigerian students. The symptoms were associated with study and manifesting a range of emotion and somatic complaints. Prince named these symptoms ‘brain fag syndrome’ and it became a mental illness in Nigeria. Symptoms of the mental illness are intellectual impairment, somatic complaints, mostly complaints about pain or burning in the head and neck, complaints affectings the student’s ability to study, tense facial expressions and sensory impairment. He stated: “most often the symptoms commenced during periods of intensive reading and study prior to examinations or sometimes just following periods of intensive studying” (PRINCE 1960:559-70). When looking at the symptoms of ‘Brain fag syndrome’ we can recognise many of them as symptoms students in the UK suffer from. However in the UK these symptoms are seen as normal behaviour. We could suggest that how ‘Brain fag syndrome’ is a syndrome in Nigeria and normal in the UK this also happens the other way around. This leads to the conclusion: we cannot diagnose an individual with a mental illness since there are cross-cultural differences. However, it could be that ‘Brain fag syndrome’ is an actual mental illness. By diagnosing an individual with it they will have help to feel less stressed. Instead of it being a “wrong” diagnosis in Nigeria it could actually be mentally abnormal thus it should be a diagnosis in the UK. It can be seen there are different diagnosis of mental illness across different cultures. We can state that it is not appropriate to label someone from a different culture with the mental illness from the Western culture.
The effect of the diagnosis
There are also studies looking into what happens when you get a diagnosis of mental illness and how this influences your life. These studies are significant as it shows that a diagnosis of mental illness helps the patient take care of themselves. It also validates their behaviour, with this the patient himself and its surroundings can acknowledge his behaviour and help him to improve its behaviour.
A study conducted by Brunner et al (1978) looks into the effects of diagnosing an individual with a mental illness. A woman came to the University Hospital of Nijmegen in the Netherlands and told them many men in her family seemed to have some kind of mental debility. One of the men had tried to rape his sister, another tried to run his boss down with his car and a third one had forced his sister with a knife to undress for him. In 1962 her granduncle had made a family tree where they found that 9 other males had this violence. Three decades later Han Brunner and his colleagues found what was wrong with the woman’s family. They had studied 5 of the males from the family and used 2 carrier females and one non-carrier female as control comparing them with 3 clinically affected males. The females are not affected by the condition but they can carry it in their genes and their sons can inherit it. They found that all the males acted aggressively when angry. The men with a lot of violence suffered from a genetic defect in their X chromosome. It damaged monoamine metabolism which is linked with the enzyme monoamine oxidase A (MAOA). Only men were affected by this because it is the X chromosome which is responsible for the production of MAOA. Because men only have one X chromosome they feel the effect of the defect. Brunner concluded that it most likely was the defect in the gene causing mental retardation and the aggressive behaviour in the males (Brunner et al,. (1993) – Genes and Serotonin | Psych Yogi). A problem with Brunner’s research can be found when looking at the reliability of the method. The study was only done once on one Dutch family. The results were not repeated with a different family so we do not know what would happen if we would find another family with the MAOA gene, would they have the same reaction and also be very violent? We also do not know for sure if the gene actually caused mental retardation because they did not do another research with different participants. The impact of this problem can be found when looking at the conclusion, the defect in the gene most likely caused mental retardation and the aggressive behaviour in males, because we do not know for sure if it was the gene causing the mental retardation or something else since they only conducted the study on one family. The study shows us that it can be appropriate to label someone with a diagnosis of mental illness. When diagnosed with a mental illness the individual will know what to be careful of. The patient knows they are ill and that they have to be careful of certain symptoms. It is shown that a diagnosis of mental illness helps an individual cope with their illness. Thus we can state that it can be appropriate to label someone with a mental illness as it helps them cope in society.
A theory looking into the effect of diagnosing an individual with a mental illness is the self fulfilling prophecy.
Robert K Merton created the term self fulfilling prophecy in 1948 so he could describe a false behaviour that directly or indirectly causes itself to become true. In other words, it is a prediction we make before we start something and by predicting it, it will come true. For example, when you have a test and you go into the classroom thinking I will fail this test, you already have a strong belief that you will not do well so the chance of you actually not doing well is way bigger. Research done by Scheff looks into the self fulfilling prophecy within people diagnosed with a mental illness. He argued that a mental illness is the result of social influences and the society. He said that a society has certain unspoken rules. When there are actions done that are seen as deviant according to those “rules” the society does not know how to react. To understand those actions and be able to explain them, a label of mental illness is placed. Because of the label of mental illness expectations are placed over these individuals, after a time they start to change their behaviour to fulfill the label they got. The exact process of the self-fulfilling prophecy according to Sheff is that it starts with individuals learning cultural stereotypes through TV. Then people internalize these stereotypes. Once an individual is labelled as mentally ill, these internalized ideas become relevant: they come to dominate one’s self concept. That individual then realises what others expect of him as mentally ill (Scheff, Thomas J. 1984. Being Mentally Ill).
From Scheff’s theory it can be stated that a mental illness can be created by society. The individual follows then the criteria of their mental illness and starts acting towards it. Because of this it is not appropriate to label someone with a diagnosis of mental illness as it is behaviour guided by the rules of society.
Conclusion
Coming to a conclusion we can see that even though when being diagnosed with a mental illness it can help the individual recognise what is happening to him and it validates why they are behaving like this (Brunner et al, 1978). The methods that are used to diagnose a mental illness like the DSM are inaccurate. We can see how there is no concurrent validity since there can be different interpretations of the mental illness and there is no way to measure the illness in the patient. Using abnormality, which has various ways to measure mental illness does not coherently define what abnormality is. When using these ways it leads to many inaccurate diagnosis’ and wrong treatments.
The studies that are done to investigate the reliability of a diagnosis shows us how every day behaviour is seen as Schizophrenic behaviour. Rosenhan’s study suggest how psychiatrist cannot distinguish every day behaviour with actual symptoms of Schizophrenia leading to a wrong diagnosis which stay with the individual for life. Looking at the cultural aspect of diagnosing a mental illness it shows how there is a cultural bias towards other cultures. As shown in Littlewood & Lipsedge and Fernando’s researches how being from an ethical background leads to more diagnosis of mental illness. Being labelled with a diagnosis of mental illness can lead to an individual living up to the diagnosis to fit into society.
Putting these factors together we can see how the diagnosis of a mental illness is not accurate because these factors lead to a wrong diagnosis. By giving a wrong diagnosis the individual will not be able to function in society due to the diagnosis. In further investigation I would like to investigate the appropriateness of treatment of a mental illness.