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Chapter 3 – Classification and DiagnosisChapter 3 – Classification and Diagnosis Copyright © 2014 John Wiley & Sons, Inc. All rights reserved.
How do we understand the individual person?Each mental patient is unique and presents a combination of genetic factors, life experiences, and current circumstances that affect behavior We need to assess individual factors but at the same time compare this patient’s behavior to a general body of knowledge based on the investigation of may people with similar symptoms We search for common patterns of behavior that would enable us to assign this patient to a category of mental illness .That is, to classify. Copyright © 2014 John Wiley & Sons, Inc. All rights reserved.
Important Aspects of a Classification SchemeClassification: a way for scientists to organize, describe, and relate the subject matter of their discipline Validity: whether a classification scheme is accurately capturing reality Utility: how useful a classification scheme is Diagnosis system: a classification based on rules used to organize and understand diseases and disorders When the rules are applied to the symptoms of one person we get a diagnosis for the symptoms in this person Copyright © 2014 John Wiley & Sons, Inc. All rights reserved.
Important Aspects of a Classification SchemeCategorical approach: an object is determined to be a member of a category or not (e.g., depressed or not depressed); Qualitative difference between the various categories Dimensional approach: an object differs in degree from others – a continuum (e.g., mildly depressed, moderately depressed, severely depressed) Prototype model: members of a category may differ in degree to which they represent a common example (used in DSM); this is a quantitative approach – members differ in quantity- how much the have of the dimension (e.g. depression) Copyright © 2014 John Wiley & Sons, Inc. All rights reserved.
An examples of a Dimensional ApproachThomas Achenbach identified two broad dimensions of behaviors in children: Externalizing and Internalizing The child’s behavior can be described on the basis of the intensity of the externalizing or internalizing behaviors Copyright © 2014 John Wiley & Sons, Inc. All rights reserved.
Copyright © 2014 John Wiley & Sons, Inc. All rights reserved.The Purpose of a Diagnostics System for Mental Disorders (Exhibit 3.1 p. 67) Provide a description of the patient’s condition Reflect the best scientific knowledge of psychopathology Provide a common language for mental health professional and also patients Indicate possible causes (etiology) Indicate possible outcomes (prognosis) Provide guidance on co-existence Provide guidance on treatment option Copyright © 2014 John Wiley & Sons, Inc. All rights reserved.
Defining Abnormal BehaviorWhat is abnormal? Many factors need to be considered including: The cultural and societal context Whether there is distress or discomfort Whether the problem is harming others How common the problem is How much it is interfering with a person’s ability to function If it is common for that person’s developmental stage (developmental psychopathology) Copyright © 2014 John Wiley & Sons, Inc. All rights reserved.
Diagnosis and Defining DisorderNo diagnosis is based on a single symptom DSM-IV-TR defines disorder in a complicated fashion including Symptoms associated with distress or impairment/disability Increased risk of suffering Culturally atypical Not just deviant behavior (unless there is also dysfunction) Copyright © 2014 John Wiley & Sons, Inc. All rights reserved.
Developmental Psychopathology Common in Child AssessmentDevelopmental psychopathology is an approach to describing and studying disorders of childhood and adolescence in a way that stresses the importance of developmental processes and tasks One needs to be familiar with the sequence and the timing of developmental milestones Copyright © 2014 John Wiley & Sons, Inc. All rights reserved.
Developmental Psychopathology (cont-d)To understand maladaptive behavior, one must view it in relation to what is considered normative Abnormal development involves continuities and discontinuities, with both quantitative and qualitative changes in patterns of behavior over time Copyright © 2014 John Wiley & Sons, Inc. All rights reserved.
Diagnosis and Defining DisorderWakefield – Harmful Dysfunction: the problem must be clear and there must be harm to person or others Dyscontrol: impairment must be involuntary or not readily controlled Diagnosis criteria always include a cluster of symptoms (a syndrome) that co-occur Copyright © 2014 John Wiley & Sons, Inc. All rights reserved.
The Development of DisordersMost all contemporary models are biopsychosocial – but different theories represent different emphases Some models emphasize biological aspects while others emphasize psychological or social aspects Life stress model – important impact of the number of life stressors on the development of disorders Copyright © 2014 John Wiley & Sons, Inc. All rights reserved.
The DSM Approach to Diagnosis: HistoryFirst edition of DSM (1952) had fairly vague terms and emphasized psychodynamic contributions DSM-II (1968) was less psychodynamically focused as medications were more commonly being used DSM-III (1980) guided by Robert Spitzer, was atheoretical (revision done in 1987) Focus on diagnostic criteria, multiaxial, increase in focus on reliability Copyright © 2014 John Wiley & Sons, Inc. All rights reserved.
The DSM Approach to Diagnosis: HistoryDSM-IV (1994) Further focus on reliability ‘Work groups’ worked on clusters of disorders Text revision (diagnostic criteria unchanged) DSM-IV’TR’ completed in 2000 DSM-5 (2013) – Current Diagnostic Manual Removed some categories and diagnoses, added others Copyright © 2014 John Wiley & Sons, Inc. All rights reserved.
The DSM Approach to DiagnosisDSM-5 Defines a mental disorder as …”a syndrome characterized by clinically significant disturbance in an individual’s cognition, emotion regulation, or behavior that reflects a dysfunction in the psychological, biological, or developmental processes underlying mental functioning.” Associated with distress or disability Culturally expected response is not a mental disorder Copyright © 2014 John Wiley & Sons, Inc. All rights reserved.
The DSM Approach to DiagnosisDSM-5 Some Changes Many disorders are now grouped differently (e.g., depression, anxiety, and somatic disorders are grouped as internalizing disorder) Personality disorders, childhood disorders are not separated from other disorders as in previous versions Controversy in many of the changes, including how reliable they are, what defines a diagnosis, and what diagnoses were removed/changed Copyright © 2014 John Wiley & Sons, Inc. All rights reserved.
The DSM Approach to DiagnosisImportance of considering culture Information in the text on cultural variation Cultural bound syndromes Diagnosis should not occur if symptoms are culturally typical Diagnosis must be done in a culturally sensitive context Section on cultural formulation Attending to cultural identity Cultural explanations for disorder Cultural relationships with client and clinician Copyright © 2014 John Wiley & Sons, Inc. All rights reserved.
The DSM Approach to Diagnosis Problems/LimitationsComorbidity: when a person receives two diagnoses at once DSM attempts to decrease the likelihood of this with several exclusionary rules However, comorbidity is very common in the DSM (previous estimates >40%) Diagnoses do not account for normal reactions to life stressors (e.g., divorce, terminal illness) Copyright © 2014 John Wiley & Sons, Inc. All rights reserved.
The DSM Approach to Diagnosis Problems/LimitationsDiagnostic criteria seem to include too much of the population (sometimes 25-30% of the population) Although better than the earlier versions DSM diagnoses are not as reliable as hoped (may be due to reliance on categories) Heterogeneity of symptom profiles is problematic Polythetic nature of disorders: same diagnosis can be applied to similar and different symptoms Copyright © 2014 John Wiley & Sons, Inc. All rights reserved.
The DSM Approach to Diagnosis Problems/LimitationsValidity of some disorders is questionable (i.e., that the diagnosis is a discrete entity) Current research indicates that some disorders may be both a category and a continuum (e.g., depression) Resilience is often not included in understanding disorders, yet is a common aspect of human functioning Copyright © 2014 John Wiley & Sons, Inc. All rights reserved.
Other Classification SchemesInternational Statistical Classification of Diseases and Related Health Problems (ICD-10) – developed by World Health Org. Mental and behavioral disorders subsection (compatible with the DSM-IV) Companion “International Classification of Functioning, Disability and Health (ICF)” focused on overall functioning and health Achenbach System of Empirically Based Assessment – internalizing/externalizing problems Copyright © 2014 John Wiley & Sons, Inc. All rights reserved.
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