Professional Psychology: Research and Practice In the public domain

1996. Vol. 27, No. 3. 272-277

The Representativeness and Past-Behavior Heuristics

in Clinical Judgment
Howard N. Garb
Highland Drive Veterans Affairs Medical Center, Pittsburgh, and University of Pittsburgh

To clarify how psychologists make judgments, 3 studies were conducted. The results from 2 studies
indicate that the representativeness heuristic (D. Kahneman & A. Tversky, 1973) describes how
diagnoses are made. That is, clinicians seem to make diagnoses by comparing patients to typical
patients (e.g., the typical patient with schizophrenia). In a 3rd study, the representativeness heuristic
did not describe how clinicians make behavioral predictions. Instead, the past-behavior heuristic
was descriptive. The results can help psychologists understand why different problems occur in psy-
chodiagnosis. For example, the results suggest that when race bias and gender bias occur in psycho-
diagnosis, they occur because race or gender are features of a clinician's stereotypes, not because
clinicians are attending to base rates.

Cognitive heuristics are simple rules that describe how people
make judgments. Perhaps the most frequently discussed cogni-
tive heuristic is the representativeness heuristic. The represen-
tativeness heuristic is said to be descriptive of a person's cogni-
tive processes when the person makes a judgment about an ob-
ject or person by comparing the object or person to another
object or person (Kahneman & Tversky, 1973). For example,
when judging the likelihood of a diagnosis, a clinician may com-
pare a patient to (a) the typical patient with schizophrenia (the
clinician's stereotype) or (b) the prototypical patient with
schizophrenia (the clinician's prototype). The prototypical pa-
tient would have all of the features associated with a category,
whereas the typical patient would have only some of the features
(Horowitz, Wright, Lowenstein, & Parad, 1981). Empirical re-
search in social psychology has shown that the representative-
ness heuristic is frequently descriptive of how judgments and
decisions are made in everyday life (Tversky & Kahneman,
1982). According to Dawes (1986), the representativeness heu-
ristic is also descriptive of how psychologists make judgments.
However, until the present three studies, there was no empirical
evidence on whether or not the representativeness heuristic de-
scribes how clinicians make judgments.
Another cognitive heuristic, named here for the first time, is
HOWARD N. GARB received a double-major PhD in clinical psychology
and research methodology from the University of Illinois at Chicago in
1983. He is a clinical psychologist on an acute psychiatry unit at the
Highland Drive Veterans Affairs Medical Center in Pittsburgh and is
also a faculty member of the Department of Psychiatry at the University
of Pittsburgh.
I EXPRESS MY APPRECIATION to Brian Powell and Thomas A. Widiger
for providing two of the case histories presented to clinicians, to Wil-
liam M. Grove for his comments on a draft of this article, and to the
276 psychologists and psychology interns who participated as clinical
judges.
CORRESPONDENCE CONCERNING THIS ARTICLE should be addressed to
Howard N. Garb, Psychology Service 116B, Highland Drive Veterans
Affairs Medical Center, Pittsburgh, Pennsylvania 15206-1297.
272
the past-behavior heuristic. This heuristic refers to when people
make predictions of future behavior by looking at past behavior.
For example, to predict violence, one can consider if a person
has been violent in the past. Although Dawes (1986) and other
investigators have argued that cognitive heuristics probably de-
scribe how clinicians make judgments, they did not consider
whether the past-behavior heuristic can describe how clinicians
make predictions.
Several investigators have argued that a natural way for clini-
cians to make diagnoses is for them to compare patients to pro-
totypes (e.g., Cantor & Genero, 1986; Cantor, Smith, French,
& Mezzich, 1980; Horowitz, Post, French, Wallis, & Siegelman,
1981; Livesley, 1985). They noted that research in cognitive
psychology has shown that people in everyday settings typically
make categorical judgments by comparing people or objects to
prototypes (e.g., Rosch, 1978; though see Komatsu, 1992;
Medin, Goldstone, & Gentner, 1993). They did not argue that
clinicians actually make diagnoses by comparing patients to
prototypes. Clinicians may have a natural inclination to com-
pare patients to prototypes, but given that they are supposed to
attend to the criteria contained in the Diagnostic and Statistical
Manual of Mental Disorders (4th ed.; DSM-IV; American Psy-
chiatric Association, 1994), they may attend to the criteria
rather than compare patients to prototypes. If clinicians make
diagnoses by comparing patients to prototypes, one can say the
representativeness heuristic describes their cognitive processes.
If clinicians make diagnoses by attending to the explicit cri-
teria contained in DSM-IV, then the representativeness heuris-
tic will not be descriptive of how they make diagnoses unless
their stereotypes or prototypes coincide with the DSM-IV cri-
teria, which is extremely unlikely to happen all of the time,
given results from research on clinicians' prototypes (e.g.,
Blashfield & Haymaker, 1988; Livesley, Reiffer, Sheldon, &
West, 1987; McFall, Murburg, Smith, & Jensen, 1991). How-
ever, empirical research indicates that many clinicians do not
attend to diagnostic criteria (Jampala, Sierles, & Taylor, 1988;
Lipkowitz & Idupuganti, 1985; Morey & Ochoa, 1989). For
example, Morey and Ochoa (1989) had psychologists and psy-
 CLINICAL JUDGMENT
chiatrists make diagnoses and complete symptom checklists for
clients. Clinical diagnoses were compared to criteria-based di-
agnoses. In 72% of the cases, there was a discrepancy between
the clinical diagnoses and criteria-based diagnoses. Because
many clinicians do not attend closely to criteria, the represen-
tativeness heuristic may describe how they make diagnoses.
The purpose of the current three studies was to describe how
psychologists make judgments, especially diagnoses. In all of the
studies, psychologists were instructed to rate (a) the likelihood
of different diagnoses or the likelihood of particular behaviors
and (b) the similarity between patients and typical patients who
exemplify different diagnostic categories or the similarity be-
tween a patient described by a case history and typical patients
who behave a particular way. The evidence in social psychology
that supports the descriptive validity of the representativeness
heuristic is that participants make the same responses when told
to make similarity ratings and when told to make likelihood
ratings. As noted by Dawes (1986, p. 438):
Where is the "hard evidence" that the thinking problems outlined
in this paper are actually due to representative thinking, as opposed
to some other cognitive problem, or a variety of problems? The
most direct evidence is that subjects making judgments of repre-
sentativeness (e.g., "resemblance") make the same judgments that
they do when asked for probability estimates (Tversky & Kahne-
man, 1983, p. 297).
Study 1: Psychodiagnosis I
Method
Judges. I randomly selected eight medical centers from a list of all
Department of Veterans Affairs (DVA) medical centers with American
Psychological Association (APA)-certified psychology internship train-
ing programs. All of the psychologists and psychology interns at these
medical centers were asked to participate in this study. Of 151 clini-
cians, 67 completed questionnaires for a 44% response rate. Fourteen
of the clinicians were psychology interns and 53 were psychologists.
Instructions. Clinicians read a case history and made likelihood,
similarity, and confidence ratings. They made likelihood ratings for an-
tisocial personality disorder, histrionic personality disorder, narcissistic
personality disorder, and borderline personality disorder after reading
the following instructions:
Ratings are to be made on a scale with values ranging from 0 to 10,
with 0 indicating that the person definitely does not have the disor-
der and a rating of 10 indicating that the person definitely does. A
rating of 5 should indicate that the person has a "50-50" chance of
having the disorder. If you would make a diagnosis on the basis of
the case history, then make a rating of 8, 9, or 10.
They then rated how much confidence they had in their likelihood rat-
ings on a scale ranging from 1 to 7, with 1 indicating "I guessed," 4
indicating "The ratings reflect my impressions but I would have liked
more information," and 7 indicating "I am confident my ratings are
highly accurate." Next, clinicians made similarity ratings for each of the
four personality disorders listed above. They were told the following:
Ratings are to be made on a scale with values ranging from 0 to 10,
with 0 indicating that the person is not at all similar to the "typical"
person with the disorder and a rating of 10 indicating that the per-
son exemplifies the disorder.
273
Clinicians then rated their confidence in their similarity ratings.
Case history. The case history presented to clinicians was taken
from a study by Ford and Widiger (1989). Their case history described
a White male who met the Diagnostic and Statistical Manual of Mental
Disorders (3rd ed.; DSM-III; American Psychiatric Association, 1980)
criteria for antisocial personality disorder. The case was modified so that
the Diagnostic and Statistical Manual of Mental Disorders (3rd ed.,
rev.; DSM-HI-R; American Psychiatric Association, 1987) criteria for
antisocial personality disorder were satisfied. If one strictly adhered to
the DSM-HI-R criteria, a diagnosis of antisocial personality disorder
would be made but not a diagnosis of histrionic, narcissistic, or border-
line personality disorder though the man did have borderline personal-
ity features.
Results
Likelihood and similarity ratings. Likelihood ratings and
similarity ratings were highly correlated. With 268 pairs of like-
lihood ratings and similarity ratings (67 clinicians each made
four likelihood ratings and four similarity ratings), the correla-
tion between the two types of ratings was .92. This, by itself, is
strong evidence in support of the representativeness heuristic.
Rating scale artifacts can occur if clinicians have different re-
sponse styles. Because psychologists don't normally rate the
likelihood of a diagnosis on a 10-point scale, they might have
difficulty using the rating scale. To standardize ratings, I calcu-
lated z scores separately for each clinician. For example, for
Clinician 1, the mean and standard deviation were calculated
for the four likelihood ratings, and a z score was calculated for
each of the likelihood ratings. Then, z scores were calculated for
the similarity ratings. By calculating z scores, I standardized
means and standard deviations for all of the clinicians. A corre-
lation between the likelihood z scores and similarity z scores
was then calculated, which yielded a correlation of .96. This
correlation is not necessarily more informative than the corre-
lation calculated using raw scores, but it does give one another
way of looking at the data, and it, too, supports the descriptive
validity of the representativeness heuristic.
Eighteen of the 67 clinicians made the diagnosis one would
make if one adhered to the DSM-HI-R criteria: They made a
likelihood rating of 8 or higher for antisocial personality disor-
der but not for any of the other three personality disorders. For
these 18 clinicians, the correlation between likelihood and sim-
ilarity ratings was .93 for raw scores and .97 when the correla-
tion was calculated using z scores. Thus, even when clinicians
seem to be adhering to DSM-III-R criteria, their cognitive pro-
cesses can also be described by the representativeness heuristic.
For the other 49 clinicians, the correlation between likelihood
and similarity ratings was .92 for raw scores and .96 when the
correlation was calculated using z scores.
The test of a theory is its ability to predict. If one predicted a
likelihood rating of 8-10 when a clinician made a similarity
rating of 8-10, then one would have been accurate 246 of 268
times, for an accuracy rate of 92%. If one predicted that each of
the clinicians would make a diagnosis of antisocial personality
disorder but no other diagnosis (i.e., if one adhered closely to
DSM-III-R), one would achieve a 73% rate of accuracy (39
clinicians did not make a diagnosis of antisocial personality dis-
order, and clinicians made 34 diagnoses of histrionic, narcissis-
tic, or borderline personality disorder). The difference in accu-
274
racy for the two sets of predictions is statistically significant:
using the sign test, z = 6.1, p < .01.
Confidence ratings. If clinicians make diagnoses by making
similarity ratings, then their confidence ratings for diagnostic
likelihood ratings and similarity ratings should be similar. For
example, clinicians who reported that they could only guess at
a diagnosis because important information was not made avail-
able should also report that they could only guess when asked to
rate how similar the patient is to typical patients who represent
different diagnostic categories. Likelihood ratings and sim-
ilarity ratings were exactly the same for 55 of the clinicians,
differed by one for 11 of the clinicians, and differed by two steps
of the rating scale for one clinician.
Study 2: Psychodiagnosis II
In Study 2, a new case history was presented to a new group of
clinicians, using a different experimental procedure. Clinicians
made similarity ratings 6 weeks after they made likelihood rat-
ings. In addition to describing the validity of the representative-
ness heuristic, an attempt was made to replicate findings on race
bias in the differential diagnosis of schizophrenia and brief re-
active psychosis. Loring and Powell (1988) reported that Afri-
can Americans are more likely than Whites to be assigned a
diagnosis of schizophrenia and less likely to be assigned a diag-
nosis of brief reactive psychosis. In their study, questionnaires
were sent to a random sample of psychiatrists chosen from
membership lists of the American Psychiatric Association and
of two state psychiatric associations.
Method
Judges. Psychologists and psychology interns at five DVA medical
centers were asked to participate. The medical centers were randomly
sampled from a list of DVA medical centers with APA-certined psychol-
ogy internship training programs. Medical centers that had been sam-
pled for Study 1 were excluded from the list.
Procedure. Clinicians were to read a case history and then rate the
likelihood of the person's having schizophrenia, the likelihood of major
depression, and the likelihood of brief reactive psychosis. Approxi-
mately 6 weeks later, clinicians received a second questionnaire. They
reread the exact same case history, but they now made similarity rat-
ings, including for the categories of schizophrenia, major depression,
and brief reactive psychosis. Instructions for the likelihood and sim-
ilarity rating scales were the same as for the rating scales used in Study
1. Clinicians at two of the medical centers were told that the patient
described by the case history was African American ( when they made
both likelihood and similarity ratings), whereas clinicians at the other
three medical centers were told that the patient was White (again, when
they made both likelihood and similarity ratings).
Case history. The case history presented to clinicians was taken
from a study by Loring and Powell (1988). The case was not written so
that the patient clearly met the DSM-III or DSM-III-R criteria for
a particular disorder. The case described a 30-year-old man who was
anxious, could not concentrate, saw a black figure with horns standing
over him at night, and felt an urge to kill his wife. Loring and Powell
reported that when the patient was described as being African Ameri-
can, a diagnosis of schizophrenia was more likely than a diagnosis of
brief reactive psychosis.
Results
Response rates. One hundred seven clinicians were sent the
first questionnaire: They were to read the case history and make
GARB
likelihood ratings. Fifty-nine clinicians completed the question-
naire, for a response rate of 55%. Forty-seven of them were psy-
chologists, and 12 were psychology interns. Twenty-eight of
these 59 clinicians also completed the second questionnaire
(i.e., they also made similarity ratings), for a response rate of
47%. Twenty of them were psychologists, and eight were interns.
Correlations between likelihood ratings and similarity rat-
ings. With 84 pairs of likelihood ratings and similarity ratings
(28 clinicians made ratings for three different diagnostic
categories), the correlation between the two types of ratings was
.77. When raw scores were transformed to z scores, the correla-
tion between likelihood ratings and similarity ratings was .78.
Analysis of likelihood ratings. Twenty-eight of the clinicians
were told that the patient was White. Their mean likelihood
ratings were 3.0, 4.8, and 4.3 for schizophrenia, major depres-
sion, and brief reactive psychosis, respectively. Thirty-one of the
clinicians were told that the patient was African American.
Their mean likelihood ratings were 3.4, 5.0, and 5.3, for schizo-
phrenia, major depression, and brief reactive psychosis, respec-
tively. The difference between the mean likelihood ratings for
schizophrenia was not statistically significant, t ( 5 1 ) = .53, p >
.05, nor was the difference between the two mean likelihood
ratings for major depression statistically significant, t(57) =
.26, p > .05. Unlike the results reported by Loring and Powell
(1988), in this study's results, when the patient was described
as being African American, the mean likelihood rating for brief
reactive psychosis was larger than when the patient was de-
scribed as being White, though the difference between the
means was of only borderline statistical significance, /(57) =
1.60, .05<p<.10.
Study 3: Prediction
Method
Judges. Psychologists and psychology interns at 18 DVA Medical
Centers were asked to make (a) predictions and similarity ratings or (b)
base rate estimates. The medical centers were randomly sampled from
a list of DVA medical centers with APA-certified psychology internship
training programs. Medical centers that had been sampled for the pre-
vious two studies were excluded from the list. At any particular DVA
medical center, all of the clinicians were assigned the same task (make
predictions and similarity ratings or make base rate estimates).
Procedure, instructions, and rating scales. One group of clinicians
was instructed to read a case history and make a set of behavioral pre-
dictions and a set of similarity ratings. Behaviors to be predicted were
as follows: (a) patient will physically harm another person during the
next 6 months, (b) patient will abuse alcohol (will meet DSM-III-R
criteria) in next 6 months, and (c) patient will comply with treatment
and be cooperative while in the hospital (e.g., will not refuse medicine,
will not refuse to meet with psychologist). Predictions were to be made
on a 10-point scale, with 0 indicating that the behavioral outcome would
definitely not occur, 10 indicating that the event was certain to occur,
and 5 indicating that the chances were 50-50 that the event would occur.
For the similarity ratings, clinicians were to think of patients who have
been violent, patients who have abused alcohol, and patients who have
complied with treatment (e.g., did not refuse their medicine, did not
refuse to meet with the psychologist). They were to compare the patient
described in the case history to typical patients who have been violent,
typical patients who abuse alcohol, and typical patients who comply
with inpatient treatment. Ratings were made on a 10-point scale, with
 CLINICAL JUDGMENT
0 indicating the patient was not at all similar to the typical patient and
10 indicating the opposite.
The second group of clinicians made base rate estimates. They were
not given the case history. They were instructed to estimate the percent-
age of patients who will physically harm another person during the next
6 months, the percentage who will abuse alcohol (will meet the DSM-
IlI-R criteria for alcohol abuse) in the next 6 months, and the percent-
age who will comply with treatment and be cooperative while in the
hospital (e.g., will not refuse medicine, will not refuse to meet with the
psychologist). Ratings were to be made for men in their 40s who are
admitted to psychiatric wards in DVA medical centers.
The study was conducted in the summertime. Interns begin their
training in the fall, and one cannot expect them to have a clear idea
about base rates and typical patients until they have been on station for
several months.
Case history. The following case history was based on the medical
record for a patient I had been seeing in inpatient treatment. A few
minor changes were made to protect his identity.
Identifying information: Veteran is 44 years old, White, married,
unemployed, and 100% service connected [he receives a disability
pension from the DVA ]. He was received on a 303 commitment [a
20-day commitment] from a community hospital.
History of present illness: The veteran assaulted his wife and the
staff at a community hospital. He was taken to the community hos-
pital by the state police and was placed in full restraints. He was
kept at the community hospital for 5 days and was medicated with
lithium, serentil, cogentin, and ativan. At home, he had not been
taking his medications, and he was abusing alcohol and marijuana
for 4 days. According to his wife, he was paranoid, delusional, hal-
lucinating, and threatening.
Past medical and psychiatric history: The veteran is service con-
nected for schizophrenia. He has a past history of substance abuse,
assaultive behavior, and noncompliance to treatment. He also has
a history of one suicide attempt by cutting his wrists. He was last
hospitalized at our DVA medical center in April 1992.
Review of systems: The veteran has no physical complaints. He is
overweight.
Mental status examination: Speech is slurred. Thinking is disorga-
nized. Flight of ideas. He made paranoid statements accusing his
wife of cheating. Affect is very flat. Mood is subdued. Denies cur-
rently having hallucinations. Did not verbalize a plan of suicide
or homicide. Oriented. Concentration is poor as are insight and
judgment.
Diagnoses:
I. Schizoaffective disorder; mixed substance abuse, alcohol and
marijuana.
II. No diagnosis.
Results
Response rates were good. Of 178 clinicians asked to make
predictions and similarity ratings, 85 psychologists and 22 psy-
chology interns completed questionnaires, for a 60% response
rate. Of 169 clinicians asked to make base rate estimates, 52
psychologists and 22 psychology interns completed question-
naires, for a 44% response rate.
Clinicians believed that the patient was likely to abuse alcohol
and become violent again (mean prediction ratings of 7.91 and
6.04, respectively). They were unsure if he would comply with
275
treatment as an inpatient (mean prediction rating of 5.13). In
contrast, they believed the patient was similar to other violent
patients (mean similarity rating of 5.98) but less similar to
other patients who abuse alcohol or to patients who comply
with inpatient treatment (mean similarity ratings of 4.86 and
3.43, respectively).
The correlation between prediction ratings and similarity rat-
ings was relatively low. With 320 pairs of prediction ratings and
similarity ratings (107 clinicians made predictions and sim-
ilarity ratings for three tasks, but a rating for one clinician on
one task was missing: 107 X 3 = 321 and 321 - 1 = 320), the
correlation between the two types of ratings was .416 (r 2 value
of .1732). When raw scores were transformed to z scores, the
correlation between likelihood ratings and similarity ratings
was .19. For the three tasks (violence, alcohol, compliance with
treatment), correlations between predictions and similarity rat-
ings were .42, .22, and .63 using the raw scores and .04, .06, and
.49 using the z scores, respectively.
If clinicians were attending to base rates, then one would ex-
pect the addition of the base rate estimates to the similarity rat-
ings to lead to an increase in the amount of variance explained.
Mean base rate estimates were 5%, 35%, and 61% for violence,
alcohol abuse, and compliance with inpatient treatment, re-
spectively. When the similarity ratings and base rate estimates
were used to predict the prediction ratings, a linear regression
analysis yielded an r2 value of only. 1743 (r = A17).
Discussion
The results of the three studies indicate that the representa-
tiveness heuristic describes how clinicians make diagnoses but
not how they make predictions. In the studies on diagnosis, cor-
relations between likelihood ratings and similarity ratings were
.92 (r 2 = .85) and .77 (r2 = .59). In the prediction study, the
correlation between predictions and similarity ratings was only
.42 (r 2 = .17). The correlation of .77 was obtained when clini-
cians made diagnoses in one sitting and similarity ratings (after
reading the same case history) several weeks later—making the
discrepancy between the results for diagnosis and prediction
even more pronounced. It is interesting that the representative-
ness heuristic was descriptive of how clinicians made diagnoses,
regardless of whether or not clinicians attended to DSMcriteria
(see Study 1).
There is a compelling reason why the representativeness heu-
ristic did a relatively poor job of describing how clinicians made
predictions. When clinicians use past behavior as the best pre-
dictor of future behavior, similarity ratings will not necessarily
be highly correlated with prediction ratings. A patient may have
performed a behavior in the past but be dissimilar to other pa-
tients who have performed the behavior. For example, the pa-
tient described by the case history in Study 3 had abused alco-
hol in the past, but several clinicians commented that he was
not typical of alcohol abusers treated in the DVA system (e.g.,
one clinician wrote, "Not similar to alcoholics in our popula-
tion—most of our alcoholics are not psychotic"). In fact, for
the prediction of alcohol abuse, the mean prediction rating was
7.91, whereas the mean similarity rating was only 4.86, indicat-
ing that clinicians thought he would abuse alcohol even though
he was not similar to other patients who abuse alcohol.
276
One limitation of the studies is that the results do not clarify
if clinicians make diagnoses by attending to stereotypes or pro-
totypes. For the similarity ratings, clinicians were instructed to
compare patients to stereotypes (e.g., the typical patient with
schizophrenia). They could have been instructed to compare
the patients to prototypes (e.g., the prototypic patient with
schizophrenia). Because ratings for stereotypes and ratings for
prototypes can be highly correlated, one cannot conclude from
the results of the present studies that clinicians compared pa-
tients to stereotypes rather than prototypes when they rated the
likelihood of different diagnoses. Also, when clinicians com-
pared the patient to stereotypes, it is not clear if they compared
the patient to a theoretical stereotype or to patients they have
worked with in the past who exemplify a category (see Genero
& Cantor, 1987, for a related discussion on summary proto-
types and exemplar prototypes). Still, one may conclude that
the representativeness heuristic is descriptive of clinicians' cog-
nitive processes when they make diagnoses.
Another limitation is that each study used only one case his-
tory. Stronger conclusions could be reached if clinicians had
made ratings for more cases.
One should not conclude that the representativeness heuristic
will never describe how clinicians make predictions. There may
be instances when clinicians do not use past behavior to predict
future behavior; this can occur because a change in the person's
condition or environment makes past behavior less valuable as
a predictor. For example, a neuropsychologist may believe that
past behavior is largely irrelevant when predicting if a person
who has suffered head trauma can return to work. When clini-
cians are not using past behavior to predict future behavior, the
representativeness heuristic may describe how they make
predictions.
The results have important implications for problems that
occur in diagnosis. For example, although reliability is fre-
quently fair (Grove, 1987; Matarazzo, 1983), relatively low re-
liability will occur if clinicians attend to stereotypes or proto-
types and if the stereotypes and prototypes vary from clinician
to clinician. Prototypes have been found to differ from clinician
to clinician, and important differences have been found be-
tween clinicians' prototypes and DSMcriteria (e.g., Blashfield
& Haymaker, 1988; Livesley et al., 1987; McFall et al., 1991).
The results also suggest that when race bias or gender bias occur
in diagnosis (e.g., Ford & Widiger, 1989; Loring & Powell,
1988), they occur not because clinicians are attending to base
rates but because race or gender are features of a clinician's ste-
reotypes. When the representativeness heuristic is descriptive of
cognitive processes, one can infer that a clinician is not attend-
ing to base rates (e.g., Kahneman, Slovic, & Tversky, 1982). If
clinicians compare patients to patients they have worked with
who exemplified a diagnostic category, the clinician may be in-
fluenced by the race or gender of the exemplary patients. Fi-
nally, if clinicians make diagnoses by comparing patients to ste-
reotypes or prototypes, their diagnoses may have poor validity.
Clinicians form stereotypes and prototypes in part on the basis
of their clinical experiences. Clinicians frequently have trouble
learning from their experiences in clinical settings, in part be-
cause they do not always receive accurate feedback, especially
with regard to diagnosis (Garb, 1989). This is true for neuro-
GARB
psychologists as well as for psychiatrists and clinical and coun-
seling psychologists (Garb & Schramke, in press).
To improve diagnosis, clinicians should attend to the DSM
criteria. The DSM-IV contains simplified criteria, and this
should make it easier for clinicians to attend to the criteria
(Widiger, Frances, Pincus, Davis, & First, 1991). By using
semistructured interviews, clinicians may also be more likely to
adhere to criteria (at least they would be constrained to ask
about the symptoms and behaviors reflected in the criteria.)
Though the focus of the studies was on the representativeness
heuristic, results were also obtained on race bias (Study 2). Af-
rican Americans and Whites were equally likely to be diagnosed
as having schizophrenia or major depression, and there was a
nonsignificant trend for African Americans to be more likely to
be diagnosed as having a brief reactive psychosis. Loring and
Powell (1988) reported that African Americans were more
likely to be diagnosed as having schizophrenia, and Whites were
more likely to be diagnosed as having a brief reactive psychosis.
Their results may have differed from the results reported in this
article because many of their clinicians were in private practice
and did not work with psychotic patients. Though race bias was
not found in the present group of studies, it remains a signifi-
cant problem, especially in the differential diagnosis of schizo-
phrenia and bipolar affective disorder (Mukherjee, Shukla,
Woodle, Rosen, & Olarte, 1983; Pavkov, Lewis, & Lyons, 1989;
Simon, Fleiss, Gurland, Stiller, & Sharpe, 1973).
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Received March 24, 1995
Accepted August 21, 1995 •