Download Classification - Perfectionism and Psychopathology Lab

Classification of Psychological
Disorders
Learning Objectives
 Importance
of Classification
 Philosophical underpinnings of two
approaches to classification
 Purposes of Classification
Symbols and Language
Words are symbols
 By convention we all agree on symbols
 Why I can refer to a pen and we all know
what it is I am referring to
 If not, have to have pen directly in front of us.
 How do we come to establish symbols or
concepts that everyone can agree upon?
 Nature of classification

Classification
 Important
activity in clinical work and
research
 Basic part of science
 Information made more accessible,
meaningful, and less cumbersome
Classification
 Normal
vs. Abnormal
Charles Manson
Classification
 Need
to further define abnormal
 Divide “abnormal” into subclasses
 Mushroom example
Mushroom
Not a Mushroom
Poisonous
Edible
Bach Mai Hospital doctors treat the oldest of two brothers
who survived eating poisonous mushrooms, although six of
their families members did die.
Classification Historical
 Paradigms
have influenced how
classification done and what was
classified
 Hippocrates’ Four humors:
Hippocrates
 1.
Black Bile ---- Depression
 2. Yellow Bile ---- Tension/Anxiety
 3. Phlegm ---- Dull, Sluggishness
 4. Blood ---- Mania/Mood Swings
Historical
 Pre-history:
Likely simply divided into
normal vs abnormal
 Ancient Greece: Hippocrates
 Others over the ages: Jean Fernel (1497
– 1588); Feliz Platter (1536-1614);
Francois Baussier de Sauvages (18thC)
Philosophical Issues in Abnormal
Behaviour Paradigms
 Nature
of psychopathology, normalcy,
belief in paradigm
 Historical
– Emil Kraeplin and Neo-Kraeplians
– Sigmund Freud
 Contemporary:
– DSM & ICD
– PDM & OPDS

Two Trends
 Symptom
as Focus (Kraeplin)
 Underlying Cause as Focus (Freud)
Symptom as Focus
Group of Sx or observable behaviors
 Seen as cause of the difficulties
 Focus of assessment and treatment is on
eradicating the symptoms
 Behavior school, ICD, DSM
 Variant embraced by Managed Care in US
(i.e., insurance company)

Underlying Cause as Focus
 Problems
caused by underlying process
 Assessment and treatment focuses on
underlying process
 Orientation of psychodynamic,
cognitive behavioral (to degree), and
PDM.
Classification
 Basic
part of science
 Want to make information more
accessible, meaningful, and less
cumbersome
Classification - Purposes
 Description
and need to identify
 Communication
 Research
 Treatment
 Insurance
 Theory Development
 Epidemiological Information
Diagnosis leads to treatment
 From
medical perspective:
Appendicitis
Gas Pains
 Diagnosis
does not always lead to
proper treatment:
– Alzheimer’s Disease
– Depression and “families” of drugs
– ALS
How to Classify?
1.
Divide disorders into mutually
exclusive and collectively exhaustive
subclasses
a. Mutually Exclusive: disorders should be
distinct and cannot belong to two
different subclasses (e.g., poisonous and
edible mushrooms???)
b. Collectively Exhaustive: all disorders
must be classified
How to Classify? Cont’d
2.
Subclasses defined by necessary and
sufficient conditions
a. Must be characteristics that are necessary
for classification
b. Must also be set of sufficient conditions to
belong to a subclass
How to Classify Cont’d

Reliability: Each time you (or someone else)
uses the classification system, should get the
same result
– Need to identify psychological problems in a clear
and reliable manner
– Also need agreement among mental health
professionals or can have individuals referring to
same term to describe different disorders

E.G., Schizophrenia and “split personality”
(i.e., dissociative identity disorder)
How to Classify Cont’d
 Validity:
Classification system should
say something about the “true world”
DSM – IV Text Revision
DSM’S
Categorical Approach to define abnormality
 Revised periodically:

–
–
–
–
–
–
–
DSM first published 1952
DSM II published 1968
DSM III published 1980
DSM III Revised published 1987
DSM IV published 1994
DSM IV Text Revision 2000
DSM V published 2014
DSM
 Over
400 disorders
 DSM provides descriptive information
not based on any one theoretical
perspective (although this is
debateable)
 Categorical Approach
 Descriptive features are based on
observable features:
DSM IV TR
 Provides
–
–
–
–
information on:
Diagnostic Features
Associated Features and Disorders
Associated Laboratory Findings
Age-related, Culture-related and Genderrelated features
DSM 4 & 5
 DSM
4 – 5 axes
 DSM
5 - No Axes – Different Disorders
Pros and Cons
 Pro:
– Reliability has improved over previous
editions
– Provides information on research and
reliable and valid information
– Axis IV and V very good in terms of
attempting to take into account many
factors
Pros and Cons
 Con:
– Only first 3 Axes tend to used and even
then Axis 2 used inappropriately
– Labeling and stigma still issue
– Biological tests not used
– Fees paid based on diagnosis and some
patients diagnosed inappropriately
– Doesn’t lead to differential treatment
decisions for most part
– Still very subjective
DSM IVTR (p. XXXIV)

“ DSM-IV is a categorical classification that
divides mental disorders into types based on
criteria sets with defining features….. In
DSM-IV there is no assumption that each
category of mental disorder is a completely
discrete entity with absolute boundaries
dividing it from other mental disorders or
from no mental disorder”
Diagnosis and Formulation
 Diagnosis:
Assigning diagnostic
category
 Formulation: Attempt to explain
genesis, maintenance, and process
related information for treatment
 Struct. Interview  Diagnosis
 Assessment  Formulation
 Most
clinicians agree that need both,
although likely majority indicate that
formulation is actually more important
Other Diagnostic Manuals in
Use
Other Diagnostic Manuals in
Use
Psychodynamic Diagnostic Manual
(PDM)
PDM

DSM provides one level of description
– Some argue don’t measure some of the most
important things

PDM:
– there is more to people than what is described in
DSM
– Attempts to describe and categorize elements not
found in DSM
– Attempts to provide information that will
improve comprehensive treatments
PDM
 Not
developed to supplant DSM but to
supplement DSM
 Developed from a theoretical
perspective: Current Psychodynamic
Theory:
– Psychoanalysis
– Object Relations
– Attachment Theory
PDM
 Diagnostic
framework
 Describes the whole person:
– Surface and deeper levels of personality,
person’s emotional and social functioning
– Based on current neuroscience and
treatment outcome studies
PDM Developed By
 American
Psychoanalytic Association
 American Academy of Psychoanalysis
 International Psychoanalytic
Association
 American Psychological Association
Division 39
 National Membership Committee on
Psychoanalysis in Clinical Social Work
PDM
 The
–
–
–
–
elements include:
Personality patterns
Social and emotional capacities
Unique mental profiles
Personal experiences of individuals
PDM- Rationale
 Human
behaviour is complex
 DSM simplifies behaviour too much
 Want to direct focus on full range of
affect, thought, behaviour in context of
an individual’s own unique history
PDM- Rationale Cont’d
Consistent with idea that:
Rather than thinking of people
having discrete disorders (i.e., ego
dystonic, separate, outside of self), see
disorders as result of some process
(personality, incorporation of
upbringing, etc.) and the process is
what is important
PDM Dimensions
1.
2.
3.
Personality Patterns and Disorders (P
Axis)
Mental Functioning (M Axis)
Manifest Symptoms and Concerns (S
Axis)
P Axis
 Person’s
location on Continuum:
Healthy -----------------Disordered
Ways in which person organizes
mental functioning and interacts with
world
 Maxim: Need to understand person in
order to understand problem

P Axis
Includes many of the Axis II diagnoses from
DSM
 Adds other ones that are seen as extremely
important:

–
–
–
–
–
Depressive Personality Disorder
Sadistic and Sadomasochistic PD
Masochistic (Self-defeating) PD
Somatizing PD
Dissociative PD
M Axis

Detailed look at emotional functioning
– E.G., Information processing, selfregulation, relationships, emotional
expression, learning, coping/defenses, etc.
S Axis
 Using
the DSM categories, focus on
personal experience of difficulties
 Need to be seen in context of
personality and mental functioning
PDM
 Attempt
to develop a thorough and
comprehensive diagnostic picture
 Takes whole person into account
PDM
Published in 2006 so little early to evaluate
 Welcomed by most clinicians as an addition
to aid in treatment planning
 Aids in formulation:

– Diagnosis doesn’t give you all relevant
information for treatment
– Need to determine etiology, maintenance factors,
process-related issues, history of relationships, etc.
which guide treatment
Other Classification Systems
 ICD
– 10
 McLemore and Benjamin’s
Interpersonal Diagnosis
 Operationalised Psychodynamic
System
Classification

Discrete?
– Can people be placed in a neat diagnostic
box or not?
Discrete Categories
Male
Female
Pregnant
Not Pregnant
Classification

Continuous?
– Are the disorders on a continuum?
Nondepressed
Depressed
Discrete Categories?
Depressed
Normal
Not Depressed
Abnormal