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Chapter 5
Diagnosis and Classification of
Psychological Problems
First half of chapter.
By: Yvette M. Martinez, Carlos Gomez,
Mario olavarria
Why is abnormal behavior hard to define?
No descriptive feature is shared by all forms of
abnormal behavior. No one criterion for
“abnormality” is sufficient.
No discrete boundary exits between normal and
abnormal.
What is abnormal behavior?
There are 3
proposed
definitions of
abnormal
behavior…
Conformity to norms: statistical infrequency or
violation of social norms, when a person’s behavior
becomes patently deviant, outrageous, or otherwise
nonconforming, then he or she is more likely to be
categorized as “abnormal”
Subjective distress: the subjective felling of the
individual to determine if he or she is maladjusted
Disability or dysfunction: for behavior to be
considered abnormal, it must create some
degree of social or occupational problem for the
individual
Conformity to Norms:
Disadvantages
Advantages
Intuitive Appeal
The number
of
Deviations
Choice of
Cutoff Points
Cutoff Points
Cultural Relativity
Subjective Distress
What are some advantages of defining abnormal behavior
in terms of subjective distress?
-The text states that “it seems reasonable to expect that
individuals can assess whether they are experiencing emotional
or behavioral problems and can share this information when
asked to do so”.
What are some disadvantages of defining abnormal behavior in
terms of subjective distress?
-Not everyone that we consider to be “disordered” reports subjective
distress.
-The amount of subjective distress necessary to be considered abnormal.
Advantages & Disadvantages of
Disability or Dysfunction
Advantages
Little inference is required, problems in the
social and occupational spheres often prompt
individuals to seek out help
Disadvantages
Who should judge the standard for
dysfunction?
How to agree on what specifically constitutes
an adequate level of functioning
1.
1.
2.
Where does this leave us?
Some key points:
Abnormal behavior does not necessarily indicate mental illness.
Mental illness refers to: “a large class of frequently observed
syndromes that are comprised of certain abnormal behaviors
or features”.
Mental Illness
as stated in the DSM-IV-TR
is conceptualized as a clinically significant behavior or psychological
syndrome or pattern that occurs in an individual and that is associated with
present distress or disability or with a significantly increased risk of
suffering, death, pain, disability, or an important loss of freedom. In addition,
this syndrome or pattern must not be merely an expectable and culturally
sanctioned response to a particular event, for example, the death of a loved
one. Whatever its original cause, it must currently be considered a
manifestation of a behavior, psychological, or biological dysfunction in the
individual. Neither deviant behavior not conflicts that are primary between
the individual and society are mental disorders unless the deviance or
conflict is a syndrome of the dysfunction in the individual as described
above. (p.xxxi)
Important aspects of this definition:
(a)The syndrome must be associated with distress,
disability or increased risk of problems.
(b)A mental disorder is considered to represent a
dysfunction within an individual.
(c)Not all deviant behavior or conflicts with society are
signs of mental disorder.
Nosology, Classification, &
Diagnosis
Nosology Defined
Nosology (Campbell, 1989):
The study of diseases and in particular their
classification, nomenclature, and relationship to
one another including the principles for
differentiating one disease from another
(diagnosis), as well as a framework of how they
are related to each other.
An Ideal Nosology Will Describe
Specific causes
Its natural history
(subtypes)
Typical “textbook” clinical pictures and variations
treatment
Expected outcomes and sequeale without
Objective tests for its confirmation
Specific treatment outcomes”
disease
Include inclusion and exclusion criteria for each
Classification
A logical scheme for the grouping
of diseases in a rational
categories that is consistent to
the observed commonalities in
cause, manifestation, and natural
course of a disease.
Diagnosis
The determination of the grouping
and nomenclature of a patient’s
manifested present and past
symptoms that guide the
clinician’s understanding of
expected cause, course, context,
and treatment prognosis of the
patient’s presentation.
Nomenclature
The label or term that is used to concisely
communicate the results of the diagnostic
process and the identified disease (if any)
This is often confused with diagnosis, the
diagnosis essentially presents the complete
clinical picture while the nomenclature
presents a shorthand explanation.
Nomenclature changes from manual to
manual, but the diagnosis is your case
conceptualization.
Diagnosis
is a type of expert-level
categorization
1.
Communication
Empirical research in psychopathology
There are four major
advantages of
diagnosis
For research into the etiology
To suggest which mode of treatment is most
likely to be effective
Early classification system dates to
remember…
The Congress of Mental Science adopted a single
classification system in 1889 in Paris.
In 1948 the World Health Organization came out with the
International Statistical Classification of Diseases,
Injuries, and Causes of Death that included a
classification of abnormal behavior
* In 1952 the American Psychiatric Association published
the Diagnostic and Statistical Manual (important to
remember!!)
Early classification system
continued…
The first edition was known as DSM-I, it was later revised
in 1968(DSM-II).
Revised again in 1980, the DSM-III had important
changes, which included the use of explicit diagnostic
criteria for mental disorders, a multiaxial system of
diagnosis, a descriptive approach to diagnosis that
attempted to be neutral with regard to theories of
etiology, and greater emphasis on the clinical utility of
the diagnostic system, these changes have been
retained in subsequent editions.
Other revision were in 1987 (DSM-III-R), 1994(DSM-IV),
and the one most currently used DSM-IV-TR in 2000.
Early classification system
The first edition was known as DSM-I, it was later revised in
1968(DSM-II)
Revised again in 1980 the DSM-III had important changes, which
included the use of explicit diagnostic criteria for mental
disorders, a multiaxial system of diagnosis, a descriptive
approach to diagnosis that attempted to be neutral with
regard to theories of etiology, and greater emphasis on the
clinical utility of the diagnostic system, these changes have
been retained in subsequent editions
Other revision were in 1987 (DSM-III-R), 1994(DSM-IV), and the
one most currently used DSM-IV-TR in 2000
DSM-IV-TR
Diagnosis is multiaxial
Evaluation is done along five axes
Axis I indicates the presence of any of the clinical
disorders or other relevant conditions
Axis II evaluates for personality disorders and mental
retardation
Axis III highlights any medical condition that may be
relevant to the conceptualization or treatment of
individual’s Axis I or Axis II clinical disorders
Axis IV is psychosocial and environmental
problems relevant to diagnosis
Axis V is a quantitative estimate of an
individual’s overall level of functioning
General issues in classification
Categories versus dimensions
Models of Classification
1. Categorical Approach
2. Dimensional Approach
3. Prototypical Approach
Categorical Approach
An approach to assessment in which the basic
decision is whether the person is or is not a
member of the discrete grouping (p G-3, Davidson,
Neale, & Kring, 2003).
Essentially, the diagnosis is yes or no decision.
Assumptions of the Categorical Approach
pathological
1. All human behavior can be divided into
and normal categories; and
overlapping
2. These classes are discrete, nonclasses with high homogeneity
(textbook presentations) and clear
inclusion and exclusion criteria.
Butcher, Mineka, & Hooley, 2005
Models of Classification
1. Categorical Approach
2. Dimensional Approach
3. Prototypical Approach
Dimensional Approach
All individuals behavior can be classified
according to defined dimensions.
A person’s typical behavior (personality) can
be classified by different configuration of
these traits (ranging from very low to very
high) which represent strengths and
weaknesses.
Normal and abnormal is defined by specific
normative criteria (i.e. 3rd normative
percentile) on each criteria.
Categorical vs. Dimensional Systems
Categorical
Presence/absence of a disorder
Either you are anxious or you
are not anxious.
DSM is categorical
Dimensional
Rank on a continuous
quantitative dimension
How anxious are you on a
scale of 1 to 10?
Dimensional systems may better
capture an individual’s
functioning but the categorical
approach has advantages for
research and understanding
© 2004, John Wiley and Sons.
Models of Classification
1. Categorical Approach
2. Dimensional Approach
3. Prototypical Approach
Prototype
“A conceptual entity depicting an idealized
combination of characteristics that more or less
regularly occur together in a less than perfect or
standard way at the level of actual observation.”
- p. 129; Butcher, Mineka, and Holley, 2005
Prototype Approach
No member of the prototype has all the
characteristics of the prototype; however,
there is sufficient core of symptoms to
define a particular category.
However, there is often vagueness as
disorders are not exclusionary and there
may be a set of comorbidities and
similarities.
Syndromes
A collection or grouping of disjunctive, variable signs
and symptoms whose frequency of occurrence
together suggests the existence of a single
pathological or disease process that will explain
them.
Campbell, 1898; Eysenk, 1960
Causes of abnormal behavior and
mental illness
The each of the different models of
psychopathology have different
explanations of abnormal behavior.
There is also a more general model of
etiology that can accommodate a
variety of theoretical models: the
diathesis-stress model.
A diathesis refers to a vulnerability or predisposition to
possibly develop the disorder in question. A diathesis is
necessary but not sufficient to produce a mental
disorder. What is required in addition to a diathesis is
sufficient environmental stress. Stressor can be
biological or psychological in nature.
Syndromes
A collection or grouping of disjunctive, variable signs
and symptoms whose frequency of occurrence
together suggests the existence of a single
pathological or disease process that will explain
them.
Campbell, 1898; Eysenk, 1960
Categories versus dimensions
Bases of categorization
To classify psychiatric patients, one must use a wide assortment
of methods and principles
Pragmatics of classification
The classification are voted on by committees and therefore there
are compromises to the product to make it acceptable to a
heterogeneous professional clientele
Description
The DSM-IV-TR provides a through description of the diagnostic
categories and provides additional information for each
diagnosis, including the age of onset, course, prevalence,
complications, family patterns, cultural considerations,
associated descriptive features and mental disorders, and
associated laboratory finding to enhance the systems
reliability and validity.
Reliability
Refers to the consistency of diagnostic judgment by different
psychologists for the same disorders. To increase reliability
structured diagnostic interviews were developed to assess
individuals for the specific DSM criteria that appear in the
diagnostic manual.
Validity
The predominant method for establishing validity of
a syndrome is a five-stage process
Clinical description, including a description of
characteristic features beyond the disorder’s
symptoms
Laboratory studies to identify meaningful
correlates of the diagnosis
Delimitation from other disorders to ensure some
degree of homogeneity among diagnostic
members
Follow-up studies to assess the test-retest
reliability of a diagnosis
Family studies to demonstrate that the proposed
disorder tend to run in families, suggesting a
hereditary component to the disorder
1.
2.
3.
4.
5.
Bias
The two area of potential bias that have received the
most attention are sex bias and racial bias
Coverage
With the close to 400 possible diagnosis he DSM-IVTR cannot be seen as to limited in its coverage of
possible diagnostic condition. But some feel that
it may be too broad in its scope with such
inclusions as childhood development disorders
being included as mental disorders or
Premenstrual Dysphoric Disorder as a diagnostic
category
Conclusion
Classification systems allow us to establish
categories of varying width and purpose
that allow us to generalize and predict.
Clinical psychology is very much concerned
with the diagnosis, classification, and
treatment of mental illness, and the DSMIV-TR although not perfect will continue to
be used by contemporary clinical
psychologists in their research,
consultation, and practice,
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