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Chapter 7: Diagnosis and Classification Issues (176) (Defining Normality…
Chapter 7: Diagnosis and Classification Issues (176)
Defining Normality and Abnormality
Abnormality: mental disorders, psychiatric diagnoses; psychopathology
Much of clinical psychology focuses on this
What Defines Abnormality?
criteria such as personal distress to the individual, deviance from cultural norms, statistical infrequency and impaired social functioning
Jerome Wakefield: scholar who offered a theory with a more simplified definition of mental disorders in the 1990s
Harmful Dysfunction Theory: in our efforts to determine what is abnormal, we consider both scientific data and the social values in the context of which the behavior takes place; it can account for a wide range of behavior that clinical psychologists have traditionally labeled as psychopathological
Who Defines Abnormality?
definitions of abnormality are constantly debated
Diagnostic and Statistical Manual of Mental Disorders (DSM): the prevailing diagnostic guide for mental health professionals; defines mental disorders
DSM-5 Mental Disorder: a clinically significant disturbance in cognition, emotion regulation or behavior that indicates a dysfunction in mental functioning that is usually associated with significant distress or disability in work, relationships or other areas of functioning
Reflects a medical model of psychology: each disorder is an entity defined categorically and features a list of specific symptoms
Task Force: the group of leading researchers who created the specific diagnostic categories in the DSM
the task force was selected for their scholarship and expertise in their respective fields; primarily psychiatrists
efforts have been made to have a more diverse task force in more recent years, but is still primarily written by middle-aged white male psychiatrists
Why is the Definition of Abnormality Important?
Definitions have very real consequences for professionals and nonprofessionals
Proposed Criteria Set: a section in the DSM-5 which describes conditions that DSM authors decided to leave out of "official" disorders but do list as "unofficial" conditions for the purpose of inspiring clinicians and researchers to study them more
Importance for professionals: research, professional vocabulary, attention
Importance for clients: identify and demystify a nameless experience, universality, acknowledge the significance and get treatment; stigma/stereotyping, damaged self-image, legal issues
Diagnosis and Classification of Mental Disorders: A Brief History
Before the DSM
abnormal behaviors were written about in ancient societies (supernatural explanations), philosophers (Hippocrates theorized natural causes//imbalance of bodily fluids)
19th century: many cities were establishing asylums for the treatment of mentally ill (previously it was imprisonment/abuse); professionals were able to have extensive observations which resulted in categorization of types of patients (the categorization was shared among asylums/staff)
Emil Kraeplin: labeled specific categories- is a founding father of the current diagnostic system (1900)
Late 1800s/Early 1900s: primary purpose of diagnostic categories was the collection of statistical and census data
Mid-1900s: US Army and Veterans Administration developed a categorization system to facilitate diagnosis and treatment of soldiers returning from WWII; different from current DSM but influenced the first DSM
DSM-Earlier Editions (I and II)
DSM-1 was published by the American Psychiatric Association in 1952
DSM-II was a revision in 1968
The first 2 DSMs were similar to each other but different from today's DSMs: early version only had psychoses, neuroses and character disorders as the categories of disorders; definitions were not scientifically or empirically based; reflected psychoanalytic orientation of the authors; written as prose and was not generalizable or usable in practice
DSM-More Recent Editions (III, III-R and IV-TR)
DSM-III: published in 1980 and differed widely from the first two DSMs; reflected an approach to defining mental disorders that differed substantially and was longer (included new disorders)
relied on empirical data to determine disorders and definitions
specific diagnostic criteria which described symptoms that must be present to qualify for a diagnosis
psychoanalytic language was replaced by terminology that reflected no single school of thought
Multiaxial Assessment: psychiatric problems ere described on each of five distinct axes
Axis 1: episodic disorders (beginning and end)
Axis 2: stable/long-lasting disorders
Axes 3 and 4: medical conditions and psychosocial/environmental problems relevant to mental health issues at hand
Axis 5: global assessment of functioning scale- 100 point continuum describing the overall level of functioning
Revisions after DSM-III retained quantitative and qualitative changes instituted by DSM-III
DSM-5: The Current Edition
DSM-5: published in May 2013; first substantial revision of the manual in 20 years and was lead by David Kupfer and Darrel Regier but involved experts from all over the world contributing over a 12 year period
Task force was created and the members each led work groups which focused on a particular area of mental disorders; Scientific Review Committee was also created
Work Groups: reviewed the disorders listed in the previous DSM and considered proposals for revision
Scientific Review Committee: made sure there was sufficient scientific evidence to support the changes proposed by the work groups and conducted field trials for their proposed changes
website containing updates about the progress and soliciting comments was published in 2010
Authors tried to coordinate their efforts with those of the WHO and the ICD
International Classification of Diseases (ICD): the primary way that diseases are coded and categorized in many countries outside the US
Changes the DSM-5 did not make
emphasize neuropsychology (biological roots of disorders) like other types of medical conditions over behavioral symptoms; many mental disorders involve biological factors, however they do not have a way to test positive or negative for the symptoms in a conclusive way
shift toward a dimensional definition of mental disorders- viewing disorders along a continuum; was rejected because it was overly complicated and hard to justify but it might be considered in the future
dimensional approach for personality disorders- too complex and not clinically useful enough;
removing paranoid, schizoid, histrionic, dependent and narcissistic personality disorders
New disorders
attenuated psychosis syndrome: the hallucinations, delusions and disorganized speech characteristics of schizophrenia but in less intense/fleeting forms so that the person doesn't lose touch with reality
Mixed Anxiety-Depressive Disorder: symptoms of both anxiety and depression but enough to classify as an existing disorder
Internet Gaming Disorder: excessive and disruptive internet game-playing behavior; considered non substance addictive behaviors as well
New Features in DSM-5
shift from using roman numerals to enable more frequent minor updates (5.1, 5.2, etc)- hoping it will more quickly respond to new research about mental disorders
multiaxial assessment system and GAF were dropped- can result in different conceptualizations of the disorders
New Disorders in DSM-5
Premenstrual Dysphoric Disorder (PMDD): more severe version of PMS, a combination of at least 5 emotional and physical symptoms occurring in most menstrual cycles of a year that cause clinically significant distress or interfere with socialization
Disruptive Mood Dysregulation Disorder (DMDD): frequent (3/wk over a year) temper tantrums in children 6-18 years old that are below the expected level of maturity and occur in at least two settings; irritable/angry mood in between the temper tantrums- prompted by the increase/overmedication of diagnosis of children with BPD
Bing Eating Disorder (BED): resembles bulimia in that the person overindulges in food but the person doesn't compensate for the calories in behaviors; binges take place 1x/wk for 3 mos; lack of control over the eating, rapid eating, eating until overly full, eating alone to avoid embarrassment and feelings of guilt/depression afterward
Mild Neurocognitive Disorder (mild NCD): less intense version of major neurocognitive problems like dementia and amnesia; modest decline in memory, language use, attention, executive function but does not affect ability to live independently
Somatic Symptom Disorder (SSD): a combination of at least one significantly disruptive bodily symptom with excessive focus on that symptom that involves perceiving it as more serious than it really is, experiencing high anxiety about it, or devoting excessive time and energy to it
Hoarding Disorder: the person has continuing difficulty discarding possessions no matter how objectively worthless they are, and lives in a congested or cluttered home and experiences impairment on important occupations
Revised Disorders in DSM-5
major depression can be diagnosed in people who lost a loved on within the last 2 months if the clinician determines that the symptoms exceed expectations (of grief) based on the person's history/culture
Autistic disorder, Asperger's disorder and other related developmental disorders were combined into the diagnosis of Autism Spectrum Disorder because they all represented various points on the same spectrum of impairment (social communication problems, restrictive/repetitive behaviors and interests)
ADHD: symptoms appear at 7-12 years old and a person needs 5 symptoms to qualify
frequency of binge eating for bulimia nervosa was dropped to once per week (from 2x/wk)
anorexia nervosa omits that menstrual periods stop and definition of low body weight is not numeric anymore
substance abuse and substance dependence were combined into substance use disorder
Mental retardation was named intelectual disability/intelecutal development disorder
learning disabilities for reading, math and writing were combined into specific learning disorder (a single diagnosis)
OCD was removed from anxiety disorders and was given its new category which includes trichotillomania (hair-pulling), excoriation (skin-picking) and body dysmorphic disorder
mood disorders category was split into depressive disorders and bipolar and related disorders
Controversy Surrounding DSM-5
Allen Frances: the most vocal critic of the DSM-5; chair of the task force for the DSM-IV
concerned that the changes were scientifically unsound and unsafe; misdiagnoses/mislabeling and inappropriate medication use
Diagnostic overexpansion: primary criticism of DSM-5; diagnoses cover too much of normal life and were done in spite of questionable research evidence; may result in higher rates of disorders
Transparency of the Revision Process: website was maintained but the proposals for changes were vague and selective about info shared- process was out of public awareness
Membership of the Work Groups: most members were researchers and could not assess impact of their work on practicing clinicians; clinicians organized and understood disorders differently than researchers according to studies
Field Trial Problems: field trials were run to test reliability of new diagnoses in clinical settings but some of the reliability ratings were too low and a second stage to correct this was canceled
Price: DSM-5 was $199 hardback; DSM-IV was $65 in 1994
Criticisms of the DSM
strengths include emphasis on empirical research, the use of explicit diagnostic criteria, interclinician reliability, atheoretical language, facilitated communication between researchers and clinicians (common language)
Breadth of Coverage
too rapid expansion results in a list of disorders which should not all be classified as forms of mental illness
not every disorder is a mental disorder
more people at risk of stigma
more comorbidities is excessively high
Controversial Cutoffs
arbitrarily or subjectively chosen by authors
what does some of the cutoff criteria mean (i.e. significant distress or impairment)
Cultural Issues
DSM-5 includes an outline for cultural formulation and a cultural formulation interview to help clinicians assess in a culturally competent way
includes glossary of cultural concepts of distress/terms used by various cultural groups to describe specific psychological conditions
text describing a certain disorder includes comments on cultural variations
diversity of authors is lacking
to what extent are minorities included in empirical studies that guide the DSM?
implicit values of Western culture are found in the DSM
Gender Bias
some disorders are diagnosed more often in males or females
diagnoses may represent exaggerations of socially encouraged gender roles,
clinicians define mental health different for males and females and thus similar symptoms are diagnosed differently depending of gender and clinician
Nonempirical Influences
political influences/opinion
changing values in authors and society
financial concerns - health insurance payment, pharmaceutical companies sponsoring research
Limitations on Objectivity
expert consensus on how to interpret data that influences the DSM
Alternative Directions in Diagnosis and Classification
categorical approach: an individual has or does not have a disorder (yes/no category)- the way diagnoses are classified in the DSM
Dimensional Approach: the issue isn't the presence or absence of a disorder but instead the issue is on a continuum
what makes a person abnormal is an unusually high or low level of one or more characteristics of a disorder
Five-Factor Model of Personality (Big Five): each of our personalities contains same basic five factors (neuroticism, extraversion, openness to experience, agreeableness and conscientiousness) in a dimensional approach