Download Pomerantz chapter 7 ppt

Chapter 7
Diagnosis and Classification Issues
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?
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?
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
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
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
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
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
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
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
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)
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
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
New Disorders in DSM-5
•
•
•
•
•
•
Premenstrual dysphoric disorder
Disruptive mood dysregulation disorder
Binge eating disorder
Mild neurocognitive disorder
Somatic symptom disorder
Hoarding disorder
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
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
DSM-5 Controversy
• Allen Frances’ criticisms
– 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
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?
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?
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
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)