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 Choice of Cutoff Points Intuitive Appeal The number of Deviations 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 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

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: The syndrome must be associated with distress, disability or increased risk of problems. A mental disorder is considered to represent a dysfunction within an individual. 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. (NOT IN YOUR TEXTBOOK)

An Ideal Nosology Will Describe Specific causes Its natural history Typical “textbook” clinical pictures and variations (subtypes) Expected outcomes and sequeale without treatment Objective tests for its confirmation Specific treatment outcomes” Include inclusion and exclusion criteria for each disease

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. (NOT IN YOUR TEXTBOOK)

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. (NOT IN YOUR TEXTBOOK)

Diagnosis is a type of expert-level categorization Communication There are four major advantages of diagnosis Empirical research in psychopathology 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 Categorical Approach Dimensional Approach 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 1. All human behavior can be divided into pathological and normal categories; and 2. These classes are discrete, non-overlapping classes with high homogeneity (textbook presentations) and clear inclusion and exclusion criteria. Butcher, Mineka, & Hooley, 2005

Models of Classification Categorical Approach Dimensional Approach 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 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 Categorical Approach Dimensional Approach 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 (NOT IN YOUR TEXTBOOK)

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

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 DSM-IV-TR although not perfect will continue to be used by contemporary clinical psychologists in their research, consultation, and practice,