THINKING CRITICALLY Is Psychological Diagnosis Biased

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People
who experience anxiety disorders—particularly panic disorder, generalized anxiety disorder, or posttraumatic stress
disorder—are likely to display some other
mental disorder as well, most often depression (Kaufman & Charney, 2000; RoyByrne et al., 2000). Accordingly, the next
edition of the DSM may include mixed
anxiety-depression disorder, a new category describing people whose symptoms
of anxiety and depression combine to impair their daily functioning (Barlow &
Campbell, 2000; Widiger & Clark, 2000).
ANXIETY AND DEPRESSION
Chapter 12 Psychological Disorders
anxiety and depression. Second, the same symptom (such as difficulty sleeping) can
appear as part of more than one disorder. Third, although DSM-IV provides many useful diagnostic criteria, some of them—such as “clinically significant impairment”—are
open to a certain amount of interpretation. When mental health professionals must
decide for themselves whether a particular person’s symptoms are severe enough to warrant a particular diagnosis, personal bias can creep into the system (Kim & Ahn, 2002;
Widiger & Clark, 2000). All of these factors may lead to misdiagnosis in some cases.
Concern over this possibility has grown as the nations of North America and Western
Europe become increasingly multicultural and as diagnosticians encounter more and
more people whose cultural backgrounds they may not fully understand or appreciate.
Some people whose behavior differs enough from cultural norms to cause annoyance feel that society should tolerate their “neurodiversity” instead of giving them a
diagnostic label (Harmon, 2004). In the same vein, Thomas Szasz (pronounced “zaws”)
and other critics argue that the entire process of labeling people instead of describing
problems is dehumanizing, because it ignores people’s strengths and the features that
make each case unique (Caplan, 1995; Kutchins & Kirk, 1997; Snyder & Lopez, 2006, 2007;
Szasz, 2003; Wampold, Ahn, & Coleman, 2001). Calling people “schizophrenics” or
“alcoholics,” he says, actually encourages the behaviors associated with these labels and
undermines the confidence of clients and therapists about the chances of improvement.
In summary, it is unlikely that any diagnostic system will ever satisfy everyone. No
shorthand label can fully describe a person’s problems or predict exactly how that person will behave. All that can be reasonably expected of a diagnostic system is that it
provide informative, general descriptions of the types of problems displayed by people
who have been placed in various categories (First et al., 2004).
S
T H I N K I N G C R I T I C A L LY
ome researchers and clinicians worry
that problems with the reliability and
Is Psychological
validity of the diagnostic system are due
partly to bias in its construction and use. They
Diagnosis Biased?
point out, for example, that if the criteria for
diagnosing a certain disorder were based on
research that focused on only one gender, one ethnic group, or one age group, those criteria might not apply to other groups. Moreover, diagnosticians, like other people, hold
expectations and make assumptions about males versus females and about individuals
from differing cultures or ethnic groups. These cognitive biases could color their judgments and might lead them to apply diagnostic criteria in ways that are slightly but significantly different from one case to the next (Garb, 1997; Hartung & Widiger, 1998).
■ What am I being asked to believe or accept?
Here, we focus on ethnicity as a possible source of bias in diagnosing psychopathology.
It is of special interest because there is evidence that, like social class and gender, ethnicity is an important sociocultural factor in the development of mental disorder. The
assertion to be considered is that clinicians in the United States base their diagnoses
partly on a client’s ethnic background and, more specifically, that there is bias in diagnosing African Americans.
■ What evidence is available to support the claim?
Several facts suggest the possibility of ethnic bias in psychological diagnosis. For example, African Americans receive the diagnosis of schizophrenia more frequently than European Americans do (Manderscheid & Barrett, 1987; Minsky et al., 2003; Pavkov, Lewis,
& Lyons, 1989). Further, relative to their presence in the general population, African
Americans are overrepresented in public mental hospitals, where the most serious forms
of disorder are seen, and they are underrepresented in private hospitals and outpatient
465
Classifying Psychological Disorders
clinics, where less severe problems are treated (Lindsey & Paul, 1989; Snowden & Cheung,
1990; U.S. Surgeon General, 1999). Other research suggests that emergency room physicians are less likely to recognize psychiatric disorders in African American patients than
in patients from other groups (Kunen et al., 2005).
There is also evidence that members of ethnic minorities, including African Americans, are underrepresented in research on psychopathology (Iwamasa, Sorocco, &
Koonce, 2002). This lack of minority representation may leave clinicians less aware of
sociocultural factors that could influence diagnosis. For example, they might more easily misinterpret an African American’s unwillingness to trust a European American
diagnostician as evidence of paranoid symptoms (Whaley, 2001).
■ Can that evidence be interpreted another way?
Differences among ethnic groups in diagnosis or treatment do not automatically indicate bias based on ethnicity. Perhaps there are real differences in psychological functioning among different ethnic groups. If, relative to other groups, African Americans
are exposed to more risk factors for disorder, including poverty, violence, and other
major stressors, they could be especially vulnerable to more serious forms of mental
disorder (Plant & Sachs-Ericsson, 2004; Turner & Lloyd, 2004). And poverty, not diagnostic bias, could be responsible for the fact that African Americans are more often
seen at less expensive public hospitals than at more expensive private ones. Finally, there
is no guarantee that diagnostic criteria would be significantly different if more African
Americans had been included in psychopathology research samples.
■ What evidence would help to evaluate the alternatives?
So do African Americans actually display more signs of mental disorder, or do diagnosticians just perceive them as more disordered? One way of approaching this question is to conduct experiments in which diagnosticians assign labels to clients on the
basis of case histories, test scores, and the like. In some studies, the cases are selected
so that pairs of clients show about the same amount of disorder, but one member of
the pair is identified as European American and the other as African American. In other
studies, the same case materials, identified as representing either African American or
European American clients, are presented to different diagnosticians. Bias in diagnosis
would be suggested if, for example, patients identified as African American were seen
as more seriously disordered than others.
Most studies of this type have actually found little or no ethnic bias (e.g., Angold et
al., 2002; Garb, 1997; Littlewood, 1992). These results are difficult to interpret, however,
because the diagnosticians may be aware of the purpose of the study and so may go out
of their way to be unbiased (Abreu, 1999; Gushue, 2004). In fact, researchers have found
evidence of some diagnostic bias against African Americans when clinicians were unaware
of the purpose of the research (e.g., Baskin, Bluestone, & Nelson, 1981; Jones, 1982).
Bias has also appeared in studies aimed at identifying the factors that influence clinicians’ diagnostic judgments following extensive interviews with patients. For example, one hospital study found that, in arriving at their diagnoses, psychiatrists were
more likely to attribute hallucinations and paranoid thinking to African American
patients than to non–African American patients. Symptoms of mood disorders were
more likely to be attributed to non–African Americans (Trierweiler et al., 2000). As
noted earlier, these differences could reflect ethnic differences in the rate of disorder
in the population, but when people were interviewed in their own homes as part of
large-scale mental health surveys, the diagnosis of schizophrenia was given only slightly
more often to African Americans than to European Americans (Robins & Regier, 1991;
Snowden & Cheung, 1990). So the presence of ethnic bias is suggested, at least for some
diagnoses, for patients who are evaluated in mental hospitals (Trierweiler et al., 2000).
■ What conclusions are most reasonable?
Just as DSM-IV is imperfect, so are the people who use it. As described in the chapters
on social psychology and on thought, language, and intelligence, cognitive biases and