1. Chapter 1: Issues in Diagnosis: Conceptual Issues and Controversies
Scott O. Lilienfeld
Sarah Francis Smith
Ashley L. Watts

2. General Terminological Issues
Classification Versus Diagnosis
Classification: Overarching taxonomy
Diagnosis: Act of placing an individual into a category within a taxonomy
Signs Versus Symptoms
Signs: Observable indicators (e.g., crying)
Symptoms: Subjective indicators (e.g., feelings of guilt in depressed patient)
Syndrome Versus Disorder Versus Disease
Syndrome: Constellations of signs and symptoms that co-occur across individuals
Disorder: Syndromes that cannot be readily explained by other conditions
Disease: Disorders in which pathology and etiology are reasonably well understood

3. Functions of Psychiatric Diagnosis
Diagnosis as communication
Distills information in a shorthand form that aids in other professionals’ understanding of a case
Establishing linkages to other diagnoses
Locates a patient’s problems within the context of more and less related diagnostic categories
Provision of surplus information
Generates predictions about case trajectory, response to treatment, family history, laboratory research and so on.

4. Misconceptions Regarding Psychiatric Diagnosis
Mental illness is a myth
Mental illness as “acute problems in living” (Szasz, 1960)
Mental disorders cannot be clearly recognized by corresponding lesions in the anatomical structure of the body
Rebuttal: Many medical disorders cannot be traced to lesions and many lesions do not give rise to medical disorders

5. Misconceptions Regarding Psychiatric Diagnosis
2. Psychiatric diagnosis is merely pigeonholing
Diagnosing people with mental disorders deprives them of uniqueness.
Rebuttal: Diagnosis merely indicates one way in which people are alike.

6. Misconceptions Regarding Psychiatric Diagnosis
3. Psychiatric diagnoses are unreliable
Rebuttal: There are many kinds of reliability, which are frequently discrepant with each other
Evaluation of reliability hinges on the conceptualization of a disorder (e.g., high test-retest reliability may be expected for chronic disorders)
Interrater reliability for most psychiatric diagnoses is as high as that of other major medical disorders (Lobbestael, Leurgans, & Arntz, 2011; Matarazzzo, 1983)

7. Misconceptions Regarding Psychiatric Diagnosis
4. Psychiatric diagnoses are invalid
Simply descriptive labels for behavior we do not like
Rebuttal: Many psychiatric diagnoses provide surplus information (e.g., schizophrenia)

8. Misconceptions Regarding Psychiatric Diagnosis
5. Psychiatric diagnoses stigmatize people, and
often result in self-fulfilling prophecies
Lead to the interpretation of ambiguous behaviors as consistent with the psychiatric diagnosis (e.g., Rosenhan, 1973)
Rebuttal: Incorrect diagnoses may lead to stigma, but correct diagnoses may actually lead to reduced stigma by providing an explanation for otherwise unexplainable behavior (Ruscio, 2004)

9. What Is Mental Disorder?
Statistical Model
Disorder = Statistical Rarity
No guidelines for cutoff between abnormality and normality
Assumes all common conditions are normal (Wakefield, 1992)
Subjective Distress Model
Core feature of mental disorders is psychological pain
In some ego-syntonic conditions, individuals do not see their behavior as problematic (e.g., narcissistic personality disorder).
Biological Model
Disorder defined in terms of biological (or evolutionary) disadvantage to an individual (e.g., increased risk for suicide in depressed patients) (Joiner, 2006).
Some behaviors incur such disadvantage but are not disorders (e.g., military combat). Some disorders do not incur long-term decrease in evolutionary fitness but are disorders (e.g., phobias)

10. What Is Mental Disorder?
Need for Treatment
Disorder is any condition characterized by a need for medical intervention by a health professional (Kraupl Taylor, 1971)
Some conditions require medical intervention but are not disorders (e.g., pregnancy)
Harmful Dysfunction
Disorders are socially devalued (harmful) breakdowns of evolutionarily selected systems (Wakefield, 1992)
Many medical conditions are adaptive defenses (e.g., vomiting in the flu); many psychological conditions are adaptive reactions to threat
Roschian Analysis
Concept of mental disorder is inherently fuzzy
Mental disorders lack defining features and boundaries
Controversies over concept of mental disorder are inevitable and unresolvable

11. Psychiatric Classification From DSM-I to the Present
DSM-I and DSM-II
DSM-I (APA, 1952): First clear attempt at describing major psychiatric diagnoses in one manual
DSM-II (APA, 1968): Similar in scope to DSM-I; greater detail concerning signs and symptoms of disorders
Major criticisms:
Low interrater reliability for many disorders
Influenced heavily by psychoanalytic concepts of disorders
Neglected consideration of contextual factors (e.g., co-occurring medical disorders)

12. Psychiatric Classification From DSM-I to the Present
DSM-III (APA, 1980) and Beyond
Dramatic increase in coverage of disorders and detailed guidelines for making diagnoses
Standardized Diagnostic Criteria
Signs and symptoms of each disorder explicitly delineated
Algorithms and Decision Rules for Diagnoses
Highly structured guidelines for number of symptoms and combinations of symptoms that must be met for a diagnosis
Hierarchical Exclusions Rules
Rules to prevent diagnoses from being made if other diagnoses better account for the clinical picture

13. Psychiatric Classification From DSM-I to the Present
DSM-III (APA, 1980) and Beyond
Multiaxial Approach
Evaluations along series of axes (e.g., Axis I – Major mental disorders, Axis II – Personality disorders)
Forced a holistic approach to diagnoses
Dropped in DSM-5
Theoretical Agnosticism
Agnostic with respect to etiology of disorders
Permits use of the manual by practitioners of many different theoretical backgrounds

14. Psychiatric Classification From DSM-I to the Present
DSM-III-R and DSM-IV
Retained major features/innovations of DSM-III
Gradual move to a polythetic approach to diagnosis
Led to increased heterogeneity of diagnoses
Relaxation of many hierarchical exclusion rules (Pincus, Tew, & First, 2004)
DSM-IV added appendix for culture-bound syndromes (e.g., koro)

15. Psychiatric Classification From DSM-I to the Present
Published May 2013 (APA, 2013)
Retained most of major categories of DSM-IV
Dropped multiaxial system
Attempted to decrease proliferation of new diagnoses by necessitating rigorous validity data for new diagnoses
Criticized for lowering diagnostic threshold for several diagnostic categories (Batstra & Frances, 2012)
Criticized for inadequate field trials focusing on clinical feasibility rather than validity of new diagnostic categories (Frances & Widiger, 2012)

16. Criticisms of Current Classification System
Comorbidity
High levels of co-occurrence and covariation among many diagnostic categories
One disorder may lead to others; two disorders may mutually influence each other or be different expressions of the same underlying liability
May result from overlapping diagnostic criteria or clinical selection bias (du Fort, Newman, & Bland, 1993)
Especially problematic for personality disorders (Widiger & Rogers, 1989)
Often underestimated in clinical practice
May be attaching multiple labels to different manifestations of the same condition

17. Criticisms of Current Classification System
Medicalization of Normality
1. Increased number of diagnoses in DSMs
2. Lowered threshold for diagnoses in DSM-V (e.g., age of onset in
ADHD)
May reflect splitting of broad diagnoses into narrower subtypes (Wakefield, 2001) rather than increased coverage
DSM-V also practiced lumping of narrower diagnostic categories into broader ones (e.g., autism spectrum disorder)
Neglect of the Attenuation Paradox (Loevinger, 1957)
Efforts to achieve high reliability (especially internal consistency) may decrease validity of psychiatric diagnoses
Occurs when a narrow pool of items is used to describe a broad, multifaceted construct

18. Criticisms of Current Classification System
Unsupported Retention of a Categorical Model
DSM is exclusively categorical at measurement level- individuals either meet a diagnostic criteria for a disorder or not
Growing evidence that many DSM diagnoses are underpinned by dimensions rather than taxa (Kendell & Jablensky, 2003)
Measuring most disorders dimensionally almost always results in higher correlations with external validating variables (Craighead, Sheets, Craighead, & Madsen, 2011)

19. The DSM : Quo Vadis? Dimensional Approach
Growing evidence for dimensionality of many psychiatric conditions
Many suggest using sets of dimensions from personality science to aid in psychiatric diagnosis (Krueger et al., 2011; Widiger & Clark, 2000)
Five-Factor Model (FFM; Goldberg, 1993)
Disagreement about nature and number of personality dimensions to be used
Distinction between basic tendencies and characteristic adaptations is often neglected (Harkness & Lilienfeld, 1997)
Personality dimensions may not be sufficient by themselves to capture full variance in psychopathology

20. The DSM : Quo Vadis? Endophenotypic Markers
Accumulating research on biochemistry, brain imaging, performance on laboratory tasks and psychopathology
Widespread assumption that endophenotypic markers are more closely related to etiology than exophenotypic markers (Kihlstrom, 2002)
No endophenotypic markers of psychiatric diagnoses to date come close to serving as inclusion criteria for respective disorders
May better serve as exclusion criteria
Research Domain Criteria (RDoC): Proposed alternative to DSM; goal is to identify psychobiological systems that underlie psychopathology (Morris & Cuthbert, 2012) and markers of those systems