ODD (Oppositional Defiant Disorder) and a Big WTF?!?

[AHunter3]

TVAA:

Nice try. Pinel was not a psychiatrist. Neither was Kraepelin – although he’s now considered the Father of Psychiatry, his work was ignored throughout much of the twentieth century because of Freud. Freud wasn’t a practicing physician, and Freudian psychotherapists were generally not doctors.

Actually, this time I have to disagree. I don’t think Freud (Jung, Adler, Karen Horney, etc etc) had diddly squat to do with late 19th to early 20th Centurhy institutional psychiatry, which is to a far far greater extent the ancestor of modern psychiatry as we generally know it (a few Manhattan and Los Angeles area Freudian psychotherapists being beside the point).

As to whether or not Mssrs. Kraepelin and Bleuler actually practiced anything akin to medicine, I would not say, but they did seem to feel it important to the social success of institutional psychiatry that the bins be run by people of recognized stature and authority, and doctors were a logical choice.

People of the period had reason to believe that all the mental ailments would yield to the spotlight of science, in the same way that infectious diseases were doing; nor were they entirely wrong, as you’ve already noted. Epilepsy and syphylis are my own favorite examples.

As, again, you have already noted, the ones that they figured out got declassified as “mental illness” and those who suffer from those ailments get treated by neurologists or internists rather than psychiatrists; and what remains, a century later, in the category of “mental illness”, are the ones that are still not well understood.

And certainly there is strong temptation to say, at some point, “Gee, maybe by now the ones that have not yielded to medical research remain unsolved because the phenomena you’re trying to understand is not in fact a medical phenomenon after all.”

[Hentor_the_Barbarian]

I am not sure why I bother, as it is much more productive to simply ignore your ill-informed rantings. However, your claim was:

The distinction between psychiatry and neurology was initially that neurologists were medical professionals with degrees while psychiatrists were not.

When you are called on this, by citing that the founders of the discipline were in fact MD’s, you backpeddle by claiming that they were not psychiatrists. Pinel and Kraepelin were both MD’s who pioneered psychiatry.

You try to sidestep by re-focusing on Freudian psychoanalysts, when your original claim was more broadly psychiatrists. Again, you demonstrate your ignorance of crucial distinctions, washing across disciplines without compunction. And your assertion that psychoanalysts are not MDs is without support either.

All of this is also illustrative of your tendency to make bullshit claims that are irrelevant to the point of the thread in the first place. One spends so much time following disjointed nonsense, not a whit of it supported, that the point is lost, and apparently casual readers become unable to discern what you or others are really even saying. Useless.

[Zoe]

TVAA: I’m sufficiently well-versed in cognitive psychology and neurology to know that the distinction is not currently an operational one.

But not sufficiently well-versed enough to answer this question earlier:

Question put to TVAA:

3. you would know what psychological counseling is “supposed to be”…how?

[quote]
TVAA’s response: Ever hear of the Hippocratic Oath?

SNORT!!

TVAA has taken his rather limited experience (one that we have all shared – adolescence) and tried to bluff his way through what could have been an interesting debate. Unfortunately, he could not distinguish between what was on topic and what was not when copying, rewording and pasting from sometimes crude, often hysterically dated resources.

Although I disagree passionately with Zenster’s theories, it would have been interesting to have seen them intelligently explored without the meandering, meaningless distraction that TVAA has provided.

Experience: 20 years in inner-city high school classrooms, graduate work in developmental and educational psychology

BTW, teachers neither diagnose disorders nor perscribe medications.

[TVAA]

*Originally posted by AHunter3 *
**TVAA:

Actually, this time I have to disagree. I don’t think Freud (Jung, Adler, Karen Horney, etc etc) had diddly squat to do with late 19th to early 20th Centurhy institutional psychiatry, which is to a far far greater extent the ancestor of modern psychiatry as we generally know it (a few Manhattan and Los Angeles area Freudian psychotherapists being beside the point).

As to whether or not Mssrs. Kraepelin and Bleuler actually practiced anything akin to medicine, I would not say, but they did seem to feel it important to the social success of institutional psychiatry that the bins be run by people of recognized stature and authority, and doctors were a logical choice.

** And those doctors were viewed with disdain by “actual” physicians, who were quite contemptuous of the lack of rigor and science in psychiatry. (Of course, standard medicine wasn’t much better, but that didn’t affect their perceptions much.)

[TVAA]

*Originally posted by Zoe *
**TVAA has taken his rather limited experience (one that we have all shared – adolescence) and tried to bluff his way through what could have been an interesting debate. Unfortunately, he could not distinguish between what was on topic and what was not when copying, rewording and pasting from sometimes crude, often hysterically dated resources.

**

They’re supposed to be dated – they’re dealing with an outmoded and obsolete way ADHD was once clinically diagnosed.

Valenstein’s book was published in 1999. Nice try.

[TVAA]

*Originally posted by Hentor the Barbarian *
**The diagnostic criteria are not subject to cultural/social opinions. The question is how useful the diagnostic criteria are among different cultures.

** Bull. Since behaviors and thoughts that would otherwise be considered symptoms of mental disorder are EXPLICITLY excluded as evidence if they’re part of the patient’s cultural and religious background, this statement is either a lie or evidence of extreme ignorance.

The DSM criteria for ODD directly reference “typical” behavior of other adolescents of comparable “age and developmental level”. Necessarily included in this standard (but quietly left implicit instead of explicit) is the idea of cultural reference. Since different cultures have different ideas about how adolescents should act towards adults, different cultures will decide that a given subject fits the criteria for ODD at different points.

There are several major flaws in the DSM’s treatment; that’s merely the first.

ODD is considered to be a problem that the child has, but it’s defined by the interaction between the child and his environment.

“Clinically significant” is not a well-defined concept.

Blaming others for problems is considered a sign of ODD. However, if an easily-manipulated or -provoked person accurately claims that others “made him do” something, this is considered the same as when others do perfectly innocuous things that trigger the behaviors in question. Being significantly less psychologically mature than one’s peers is a problem, but not necessarily a medical one.

[TVAA]

Actually, upon reflection I think this claim of mine: “The distinction between psychiatry and neurology was initially that neurologists were medical professionals with degrees while psychiatrists were not” is indeed inaccurate.

Psychiatrists weren’t practicing MDs. Indeed, several of the first psychiatric journals were established because the existing medical journals refused to print their articles. Many of them had medical degrees, though, although just as many didn’t.

I stand (self-)corrected.

Since everyone is so annoyed by my supposed meanderings (which have mostly taken place because of misrepresentations made by others IMO), I think I’ll start another thread on this topic.

[Hentor_the_Barbarian]

There is no specification within the criteria nor within the description of the disorder ODD for any exclusion based on culture specific phenomena. TVAA may be thinking about such specifications for symptoms of schizophrenia, which attempt to avoid pathologizing culture-based ideas in one culture that would appear to indicate delusional thinking in others. This is irrelevant to the discussion of ODD, and is another example of his failure to make important distinctions across categories.

There are cultural or national differences in the identification of specific behavior problems. The relevant question is whether the diagnostic schema perform differently across cultures. While much more study needs to be done, in general the answer is that the constructs perform well across cultures. A very nice example of the type of work being done is: Hartman et al., (2001). DSM-IV internal construct validity: When a taxonomy meets data. Journal of Child Psychology & Psychiatry & Allied Disciplines, 42(6), 817-836. They examined data from 11 samples from the US, Canada and the Netherlands. They examined individual referents for Inattention, Hyperactivity-Impulsivity, Oppositional Defiant Disorder, Conduct Disorder, Generalized Anxiety and Depression. They examined the DSM taxonomic structure compared to three, two, and one factor models, and to a model that was unspecified. They found that “[t]he factorial structure of these syndrome dimensions was supported by the data. However, the model did not meet absolute standards of good model fit… A sharper DSM-IV model may improve the accuracy of inferences based on scale scores and provide more precise research findings with regard to relations with variables external to the taxonomy.”

Further, regarding efforts to improve the measurement of ODD, Angold and Costello (1996) examined the effects of changes in ODD diagnostic criteria from DSM-III-R to DSM-IV. They provided evidence in support of qualifications to improve the specificity of “often” for each symptom, based on a community sample, such that the criteria would identify the top 10% of the frequency of each symptom in the population. They examined the effect of the inclusion of the impairment criterion, and found that it did lead to a “fairly substantial” difference in the specific children diagnosed with the disorder, and to a subgroup who had only 2 or 3 symptoms, but were still impaired, although they were “significantly less disturbed” than those meeting criteria and having impairment. This type of work represents the scientific efforts underway to improve our diagnostic categories, and will be used in the consideration of future revisions to the DSM.

[TVAA]

Hentor, did you even read that article, or just briefly scan its summarization?

Construct validity is the degree to which the operationalizations within an experiment (or a diagnostic method) match the theoretical definition of what you’re working with (or trying to diagnose accurately). For example, if we use the Beck Depression Inventory to identify people who match the clinical population of depressed individuals, we need to first demonstrate that the BDI sorts people into groups in the way clinical standards do: in other words, we need to show that the people the test identifies as depressed are the same as the population clinical standards identify as depressed.

The article then points out that there are two general forms of diagnosis within the taxonomy of child disorders: “clinical syndromes”, which are based on hypotheses about the causes of certain types of presented syndromes, and “empirical syndromes”, which are just sets of symptoms that have been mathematically demonstrated to occur together frequently. As the article points out, no one had previously studied the degree to which the two types of diagnostic concepts gave similar results.

In short, the study found that physician’s diagnostic behavior didn’t match the “questionaire” sections of the DSM particuarly well. They concluded that part of the problem was that the wording used to describe various psychological disorders was very vague, making operationalization of the criteria difficult.

Which is what I’ve been saying.

[Hentor_the_Barbarian]

b]TVAA** I have previously read both articles closely. I have reread them for their application here. Which one are you even talking about?

I presume you are talking about the Hartman paper. You have apparently failed to understand it. I will further quote from it for you. The authors focus “…on the clinically derived DSM-IV syndromes, measuring the concepts they purport to measure using the dimensional method of factor analysis in a deductive manner.” This is exactly what they do. In short they found “…the latent structure of these six syndrome dimensions was confirmed through a consistent substantial improvement in model fit with the specification of increasingly refined syndrome dimensions in all samples.” They observe that fit was not sufficient to meet absolute standards of model fit, which means TVAA that this model is not statistically ideal. When they statistically refined the model, they "…confirmed the conclusion that the hypothesized latent structure is essentially correct. […] …by and large, items still loaded on the constructs originally designated.”

TVAA, your interpretation of this paper, if you did read it, is exceedingly dull and misrepresentative, and appears rather desperate. It is not indicative of a strong grasp of scientific endeavor. What the authors have done is provide empirical evidence that the constructs put forth by the DSM are supported as would be predicted by the empirical data across 11 samples and three countries. If this is remotely what you’ve been saying, I absolutely defy you to show me where.

They observed that varying operationalizations over the samples (the use of different interview instruments) might account for some of the lack of fit. In short, you appear unable even to digest a single research article. Better stick with your other indicated sources of information. (I think Nicole Kidman is on the latest cover – what a hottie!)

[TVAA]

[sigh]

In conclusion, the results of the present paper indicated that the DSM-IV model was consistent with the structure of the covariance patterns, as indicated by the improvement in model fit compared with simpler models. However, since the DSM-IV model did not meet the absolute standand of adequate model fit, there is substantial room for improvement. On the basis of current syndrome constructs, measurement precision may be enhanced by greater scrutiny at the operationalisation level, both with regard to the unidimensioniality of the scales and the specificity of the items for their respective syndrome dimensions. An improved DSM taxonomy may also come from sharper models which take account of common and specific components of different syndrome dimensions, the multidimensional nature of the underlying construct, and the developmental sensitivity of indicators.

–From the article in question.

Since their scales were taken directly from the DSM-IV’s standards, they’ve demonstrated that physicians’ ideas about what those various conditions are are similar but not identical to what the DSM says they are. The limitations are simple: the scales measured many different aspects of the supposed disorders, some of which will simply not apply to individual patients, and the use of ambiguous and non-specific symptoms in defining the conditions. Chief among their proposed solutions is the substitution of more precise language in the operational definitions which are less vulnerable to individual perception and judgment.

All you’ve shown is that you can quote material straight from the paper – you haven’t shown anyone that you understood anything of what you read.

And this is just internal consistency – the DSM is only a good match of what physicians consider these conditions to be. We have no idea of what its external consistency is – but we know it can’t be any better than the internal consistency. It didn’t even manage to fit the model adequately – how can it be considered to define what the disorders are if its guidelines are only loosely followed?

And they are only loosely followed in many cases… which you’ve been noticably quiet about.

[TVAA]

Now this is interesting:

J Child Psychol Psychiatry. 2003 Sep;44(6):877-87.
The effect of social context on psychiatrists’ judgments of adolescent antisocial behavior.

Hsieh DK, Kirk SA. University of California, Los Angeles 90095-1656, USA.

BACKGROUND: The DSM assumes that mental disorders can be identified by the presence of specific co-occurring symptoms associated with certain duration and impaired functioning, independent of the social context in which symptoms occur. The validity of this assumption was tested using the judgments of experienced psychiatrists. We hypothesized that psychiatrists would judge an identical set of adolescent antisocial behaviors, meeting the DSM-IV diagnostic criteria for conduct disorder, as indicative of mental disorder or non-disordered problem-in-living, depending on the social context. METHOD: A representative sample of 483 psychiatrists in the United States read one of three experimentally manipulated vignettes depicting adolescent antisocial behavior and responded to questions concerning its nature, prognosis, cause, and response to various treatments. RESULTS: Results supported our hypothesis. Under some circumstances, a youth may exhibit behaviors that meet the DSM-IV diagnostic criteria for conduct disorder, but be judged by psychiatrists as not having a mental disorder. In addition, as predicted, psychiatrists reached different judgments about course, etiology, and treatment responsiveness when the identical behaviors occurred in different social contexts. CONCLUSIONS: The findings illuminate weaknesses in the validity of classification systems based on behavioral criteria independent of their social context. Implications of findings are discussed.

** What were you saying about social factors not being an issue, Hentor?

[TVAA]

Although I’m sure you won’t regard its analysis as being particularly important (it’s not even in a journal!), the following paper is fairly interesting:

http://www.psychiatrictimes.com/p960239.html

[greck]

*Originally posted by TVAA *
**Now this is interesting:
A representative sample of 483 psychiatrists in the United States read one of three experimentally manipulated vignettes depicting adolescent antisocial behavior and responded to questions concerning its nature, prognosis, cause, and response to various treatments.
**

All that proves is that psychiatrists shouldn’t rely on vignettes to render diagnosis, prognosis, cause, and response to various treatments.

[greck]

oh, wait.

It also indicates that YOU can’t recognize flawed methodology when you see it.

[Hentor_the_Barbarian]

*Originally posted by TVAA *
**[sigh]

Yes, sigh, exactly my thoughts.

Since their scales were taken directly from the DSM-IV’s standards, they’ve demonstrated that physicians’ ideas about what those various conditions are are similar but not identical to what the DSM says they are.

??? It says that in 11 samples using varying instruments measuring similar referents for the constructs, the best model to explain the variation in the data set was the DSM. Where are you getting this “physician’s ideas are similar but not identical?” I don’t think you understand the study, so please cite whatever in the article makes you say this.

The limitations are simple: the scales measured many different aspects of the supposed disorders,

Bullshit. Be precise. What do you mean by “many different aspects?”

some of which simply not apply to individual patients,

Absolutely true. However, not once has anyone here claimed that all symptoms apply for all people. The criteria use the best empirically supported cutoff of a number of symptoms. Whoever said that all symptoms apply to all patients? Another distracter and red herring. A TVAA special.

and the use of ambiguous and non-specific symptoms in defining the conditions.

More bullshit! This study supports the structure within these disorders as anticipated by the DSM. The model described by the symptoms of the DSM was independently supported by the data. No wonder you have such problems with the DSM - you simply cannot understand the scientific inquiry that supports it.

Chief among their proposed solutions is the substitution of more precise language in the operational definitions which are less vulnerable to individual perception and judgment.

Where do they say “substitution?” This is a colored (may I suggest red) term. They suggest exactly what you have been repeatedly told - a refinement of the diagnostic schema will improve their psychometric properties, but they currently function as the best available model.

All you’ve shown is that you can quote material straight from the paper – you haven’t shown anyone that you understood anything of what you read.

Your rude remarks illustrate your lack of a position. I’ve shown that empirical evidence exists to counter your claims, which is perhaps why you avoid getting specific with your arguments, and shuck and jive when someone points out your errors, leading to “(self) corrections.”

And this is just internal consistency – the DSM is only a good match of what physicians consider these conditions to be. We have no idea of what its external consistency is – but we know it can’t be any better than the internal consistency.

External consistency? “‘Only’ a good match of what physicians consider these conditions to be?” Yes, the master of the scientific investigation. Do you mean reliability? We’ve covered this. Do you mean concurrent validity? Do you even know what you mean?

It didn’t even manage to fit the model adequately – how can it be considered to define what the disorders are if its guidelines are only loosely followed?

??? The model did not statistically fit the data, silly. But it provided the best explanation, and as you pointed out, part of the fit problem comes from the use of three different instruments. As to loosely followed, please quote from the article anything related to this assertion.

Frankly, you’ve once again demonstrated that you really have no clue. And this is only one study – one that spans 11 samples, 3 countries and varied instruments. Yet the model described by the DSM is still supported!

And they are only loosely followed in many cases… which you’ve been noticably quiet about.

How many cases? Can you specify? Can you even give a range? How often is this happening, and I’ll be happy to comment. I have already said that not all clinicians apply them as they should. This was back when your argument was that psychology was not a science.

Later, you offer:

What were you saying about social factors not being an issue, Hentor?

Again, here, people, TVAA has no problem in blending concepts and diagnoses, symptom definition and application. We were discussing cultural specificity in the symptoms of ODD. Now he makes a claim that I said social factors were not an issue, and presents an abstract describing a study with vignettes that illustrate good reliability of diagnoses in the absence of evidence that the symptoms of Conduct Disorder occur due to environmental conditions.

Look do you understand the difference between ODD and CD? Between culture and environment? Between cultural specificity of symptoms and imprecision in their application? What this suggests is that some psychiatrists have difficulty knowing what to do with the textual admonition in the DSM to be sure that the symptoms are not only the response to environmental factors when presented with a vignette that implies that they are.

When it comes to Conduct Disorder, I agree that the idea that we can presume whether the behaviors are only in response to environmental factors is an unworkable aspect of the diagnosis, and must be revised. Now, tell me how this pertains to cultural specificity of ODD symptoms?

[TVAA]

*Originally posted by greck *
**All that proves is that psychiatrists shouldn’t rely on vignettes to render diagnosis, prognosis, cause, and response to various treatments. **

No. All that proves is that you don’t have the faintest grasp of the scientific method. The only other way it would be possible to give the psychiatrists the same information – allow us to examine the similarity between their diagnostic performance – would be to show them taped psychiatric interviews of an actor pretending to be a patient who had committed those actions.

[greck]

*Originally posted by TVAA *
**No. All that proves is that you don’t have the faintest grasp of the scientific method. The only other way it would be possible to give the psychiatrists the same information – allow us to examine the similarity between their diagnostic performance – would be to show them taped psychiatric interviews of an actor pretending to be a patient who had committed those actions. **

well, help me understand this “method”

does it involve making inferences from tests that are flawed in a controlled setting and bear only modest similarity to real life?

vignettes are a poor way to study behavior, I can’t believe you’d stand behind them.

An actor is the best you can come up with? How do you control for poor acting? Would he be classically trained? Stage actor or movie? Improv?

Yeah, you’re one to criticize my knowledge of scientific method.
:rolleyes:

[Zoe]

TVAA: Valenstein’s book was published in 1999. Nice try.

But even he doesn’t argue that the science behind psychiatry is wrong or that the SSRI’s, for example, aren’t working.

[Dogface]

So, has anyone mentioned drapetomania or dysathesia aethiopica? ODD sounds a GREAT deal like dysathesia aethiopica, which is, as we all know, the mental illness afflicting slaves who are insufficiently obedient and servile.

What, never hear of it? It was characterized by a respected physician in the Antebellum South…