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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)