1. Diagnosis and Classification Issues
Chapter 7
Diagnosis and Classification Issues

2. Diagnosis and Classification Issues
Defining abnormality has been a primary task of clinical psychologists since the inception of the field
What defines abnormality?
Who defines abnormality?
Why is the definition of abnormality important?

3. What Defines Abnormality?
Various theories have suggested:
Personal distress
Deviance from cultural norms
Statistical infrequency
Impaired social functioning
Others
Harmful Dysfunction—a current theory
Jerome Wakefield
Considers both scientific data (dysfunction) and social context (harmful)
Can behaviors be culturally typical yet also abnormal?
Should the commonality of a behavior affect the way we evaluate that behaviour? Widiger and Mullins-Sweat (2008) considered the issue and came to this conclusion: “Simply because a behavior pattern is valued, accepted, encouraged, or even statistically normative within a particular culture does not necessarily mean it is conducive to healthy psychological functioning” (p. 360).

4. Who Defines Abnormality?
Authors of DSM make official definitions of disorders
Leading researchers in psychopathology
Many of these authors have been psychiatrists (DSM published by American Psychiatric Association)
Medical model of psychopathology
Categorical definitions with specific symptoms
Increasing cultural diversity among these authors in more recent editions of DSM
DSM task forces consist largely of leading researchers in various specialty areas within psychopathology who are selected for their scholarship and expertise in their respective fields. It is noteworthy that these task forces consist primarily of psychiatrists.
In DSM-5, mental disorder are defined as a “clinically significant disturbance” in “cognition, emotion regulation, or behavior” that indicate a “dysfunction” in “mental functioning” that are “usually associated with significant distress or disability” in work, relationships, or other areas of functioning (American Psychiatric Association, 2013, p. 20).

5. Why Is the Definition of Abnormality Important?
Labeling an experience as a disorder can affect professionals and clients
Professionals
Facilitate research, awareness, and treatment
Clients
Demystify difficult experience
Feel like “not the only one”
Acknowledge significance of problem
Access treatment
Stigma damages self-image
Stereotyping by those who know the client
Legal consequences

6. Before the DSM
Abnormal behavior was recognized and studied in ancient civilizations
In 19th century, asylums in Europe and U. S. arose (see Chapter 2)
Around 1900, Emil Kraepelin put forth some of the first specific categories of mental illness
Some early categorical systems were for statistical/census purposes
In the mid-1900s, the U.S. Army and Veterans’ Administration developed their own early categorization system in an effort to facilitate the diagnosis and treatment of soldiers returning from World War II. This served as a precursor to the first DSM.

7. DSM-I and DSM-II DSM-I published in 1952 DSM-II published in 1968
Similar to each other, but different from later editions
Not scientifically or empirically based
Based on “clinical wisdom” of leading psychiatrists
Psychoanalytic/Freudian influence
Contained three broad categories of disorders
Psychoses, neuroses, character disorders
No specific criteria; just paragraphs with somewhat vague descriptions
Psychoses (which would contain today’s schizophrenia)
Neuroses (which would contain today’s major depression, bipolar disorder, and anxiety disorders)
Character disorders (which would contain today’s personality disorders)

8. DSM – More Recent Editions
DSM-III
Published in 1980
Very different from DSM-I and DSM-II
More reliant on empirical data
Specific criteria defined disorders
Atheoretical (no psychoanalytic/Freudian influence)
Multi-axial assessment (5 axes)
Much longer—included many more disorders
DSM-III-R (minor changes from DSM-III) was published in 1987
The multiaxial assessment system remained in DSM through the next several editions but was dropped in DSM-5.

9. DSM – More Recent Editions
DSM-IV was published in 1994
DSM-IV-TR was published in 2000
TR stands for “text revision”
Only text, not diagnostic criteria, differ between DSM-IV and DSM-IV-TR
So, these two editions are essentially similar
The disorders in DSM-IV and DSM-IV-TR were organized into 16 broad categories, with numerous specific disorders filling each category.

10. DSM – More Recent Editions
DSM-IV included significant cultural advances
Text describing disorders often included culturally specific information
Culture-Bound Syndromes were listed
Not official diagnostic categories, but experiences common in some cultural groups
Outline for Cultural Formulation
Helped clinicians appreciate impact of culture on symptoms

11. DSM-5 Current edition of the DSM
Released in 2013
Task Force led Work Groups, each focusing on a particular area of mental disorders
Attempted greater consistency between DSM and International Classification of Diseases (ICD)
Work Groups reviewed the disorders listed in the previous DSM and considered proposals for revision, including ideas for adding, eliminating, combining, splitting, or revising the definitions of disorders.

12. Changes DSM-5 Didn’t Make
Paradigm shift to emphasize neuropsychology/biological roots of mental disorder
Dimensional definition of all mental disorders
Dimensional approach for personality disorders
Remove five of the 10 personality disorders
Proposed disorders
Attenuated psychosis syndrome
Mixed anxiety-depressive disorder
Internet gaming disorder

13. New Features in DSM-5
Naming shift from Roman numerals (e.g., DSM-IV) to Arabic numerals (e.g., DSM-5)
Minor updates will be denoted as new versions (e.g., DSM-5.1, DSM-5.2, etc.)
Elimination of the multiaxial assessment system

14. New Disorders in DSM-5 Premenstrual dysphoric disorder
Disruptive mood dysregulation disorder
Binge eating disorder
Mild neurocognitive disorder
Somatic symptom disorder
Hoarding disorder
Premenstrual dysphoric disorder – a severe version of premenstrual syndrome (PMS) including a combination of at least 5 emotional and physical symptoms occurring in most menstrual cycles during the last year that cause clinically significant distress or interfere with work, school, social life, or relationships with others
Disruptive mood dysregulation disorder – frequent temper tantrums in children 6-18 years old (at least 3 tantrums per week over the course of a year) that are clearly below the expected level of maturity and occur in at least two settings (e.g., home, school, or with friends) along with irritable or angry mood between the temper tantrums
Binge eating disorder – resembles the part of bulimia nervosa in which the person overindulges on food but lacks the part in which the person tries to subtract the calories through compensatory behaviors like excessive exercise
Mild Neurocognitive Disorder – a less intense version of major neurocognitive problems like dementia and amnesia
Somatic symptom disorder – a combination of at least one significantly disruptive bodily (somatic) symptom with excessive focus on that symptom (or symptoms) that involves perceiving it as more serious than it really is, experiencing high anxiety about it, or devoting excessive time and energy to it
Hoarding disorder – continuing difficulty discarding possessions no matter how objectively worthless they are, and as a result living in a congested or cluttered home and experiencing impairment in important areas such as work, socialization, or safety

15. Revised Disorders in DSM-5
Major depressive episode
“Bereavement exclusion” dropped
Autism spectrum disorder (new scope in DSM-5)
Encompasses autistic disorder, Asperger’s disorder, and related developmental disorders from DSM-IV
Attention-Deficit/Hyperactivity Disorder
Age at which symptoms must first appear raised from 7 to 12
Bulimia nervosa
Frequency of binge eating decreased from twice to once per week

16. Revised Disorders in DSM-5 (cont.)
Anorexia nervosa
Removed requirement that menstrual periods stop
“Low body weight” changed from numeric definition to less specific description
Substance use disorder (new scope in DSM-5)
Encompasses substance abuse and substance dependence disorders from DSM-IV
Intellectual disability disorder
Mental retardation from DSM-IV
Specific learning disorder
Covers separate learning disorders in reading, writing, and math from DSM-IV

17. DSM-5 Controversy Allen Frances’ criticisms Key areas of criticism
DSM-5 features changes that “seem clearly unsafe and scientifically unsound”
DSM-5 “will mislabel normal people, promote diagnostic inflation, and encourage inappropriate medication use”
Key areas of criticism
Diagnostic overexpansion
Questionable transparency of the revision process
Work Groups predominantly composed of researchers, not clinicians
Field trial problems
Price of DSM-5
Frances was the Chair of the Task Force for DSM-IV. He had been retired for almost a decade, with no intention of being involved in DSM-5, until he attended the annual meeting of the American Psychiatric Association in 2009 and was pulled into debate about DSM-5 by colleagues who informed him about the revision process.

18. Criticisms of Recent DSMs
Despite advances (e.g., empiricism, diagnostic criteria), some have criticized recent DSMs:
Breadth of coverage
Too many disorders? Some not actually forms of mental illness? Too many people stigmatized? Concept of mental illness becoming trivialized?
Controversial cutoffs
How many symptoms should be necessary for a particular disorder?
What constitutes “significant distress and impairment?”
Cultural issues
Some progress, but still dominated by non-minority authors and traditional Western values?
Breadth of coverage: As psychological diagnoses multiply, the chances that they overlap with each other increase, leading to a likelihood of comorbidity that some argue is excessively high.
Controversial cutoffs: Some have argued that these cutoffs have been arbitrarily or subjectively chosen by DSM authors and that historically, the consensus of the DSM experts (as opposed to empirical data) has played a significant role in these cutoff decisions.

19. Criticisms of Recent DSMs (cont.)
Gender bias
Do some diagnostic categories pathologize one gender more than the other?
Consider premenstrual dysphoric disorder
Nonempirical influences
Despite increased empiricism, do other non-empirical factors (e.g., politics, finances) influence decisions about abnormality?
Limitations on objectivity
Even with increased empiricism, do opinion and judgment still play significant roles in decisions about abnormality?
Gender bias: Some disorders are diagnosed far more often in males: alcohol use disorder, conduct disorder, ADHD, and antisocial personality disorder, to name a few. Other disorders are diagnosed far more often in females: major depression, many anxiety disorders, eating disorders, borderline personality disorder, histrionic personality disorder, and others
Nonempirical influences: The changing status of homosexuality—which was an official disorder in DSM-I and DSM-II, was a disorder only if “ego-dystonic” in DSM-III, and has been absent from the manual since DSM-III-R—reflects efforts during the 1970s and 1980s by organized groups to influence mental health establishment

20. Alternate Directions in Diagnosis and Classification
Categorical approach
The DSM’s approach
An individual falls in the “yes” or “no” category for having a particular disorder
“Black and white” approach—no “shades of gray”
May correspond well with human tendency to think categorically
Facilitates communication
Popular and professional language reflects the categorical approach: “Does my child have ADHD?”; “Some of my clients have bipolar disorder”; “Michael has obsessive-compulsive disorder.”

21. Alternate Directions in Diagnosis and Classification (cont.)
Dimensional approach
“Shades of gray” rather than “black and white”
Place clients’ symptoms on a continuum rather than into discrete diagnostic categories
Five-factor model of personality could provide the dimensions
Neuroticism, extraversion, openness, conscientiousness, and agreeableness
More difficult to efficiently communicate, but more thorough description of clients?
May be better suited for some disorders (e.g., personality disorders)
According to the dimensional approach to abnormality, each of our personalities contains the same five basic factors—neuroticism, extraversion, openness to experience, agreeableness, and conscientiousness. These five factors, rather than the disorders listed in the DSM, could constitute the dimensions on which clinical psychologists could place clients.
The authors of DSM-5 seriously considered a dimensional make-over of the personality disorders, but ultimately decided against it, at least for now.