1. Chapter 3 – Classification and Diagnosis
Chapter 3 – Classification and Diagnosis
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2. 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.

3. Important Aspects of a Classification Scheme
Classification: 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.

4. Important Aspects of a Classification Scheme
Categorical 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)
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5. An examples of a Dimensional Approach
Thomas 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.

6. 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.

7. Defining Abnormal Behavior
What 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.

8. Diagnosis and Defining Disorder
No 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.

9. Developmental Psychopathology Common in Child Assessment
Developmental 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.

10. 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.

11. Diagnosis and Defining Disorder
Wakefield – 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
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12. The Development of Disorders
Most 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
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13. The DSM Approach to Diagnosis: History
First 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.

14. The DSM Approach to Diagnosis: History
DSM-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.

15. The DSM Approach to Diagnosis
DSM-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.

16. The DSM Approach to Diagnosis
DSM-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.

17. The DSM Approach to Diagnosis
Importance 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.

18. The DSM Approach to Diagnosis Problems/Limitations
Comorbidity: 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.

19. The DSM Approach to Diagnosis Problems/Limitations
Diagnostic 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.

20. The DSM Approach to Diagnosis Problems/Limitations
Validity 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.

21. Other Classification Schemes
International 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.