Psychopathology and the DSM

Characteristics of A Useful Diagnostic System Facilitates Communication Possesses Etiological Validity Provides Reliable Information on Disabilities, Abilities, Functional Impairments, etc. Guides Research (homogeneous groups) Informs Treatment Decisions Predicts Clinical Course

History of Psychiatric Diagnosis End of the 19th century - diversity of classifications a major problem WHO adds mental disorders to International list of Causes of Death (ICD) ICD covers abnormal behavior American Psychiatric Association Publishes the DSM - I WHO publishes new classification system. APA follows with DSM-II

History of Psychiatric Diagnoses APA publishes extensively revised DSM-III, followed by a somewhat revised DSM-IIIR DSM-IV published - coordinated with the development of ICD-10 DSM-IV developed by committees - content determined through consensus and voting Committees included both psychiatrists and psychologists

Caveats Acknowledged by DSM-IV “In DSM-IV, there is no assumption that each category of mental disorder is a completely discreet entity with absolute boundaries dividing it from other mental disorders or from no mental disorder.” (p.xxii)

Caveats Acknowledged by DSM-IV “There is also no assumption that all individuals described as having the same mental disorder are alike in all important ways. The clinician using DSM-IV should therefore consider that individuals sharing a diagnosis are likely to be heterogeneous even in regard to the defining features of the diagnosis and that boundary cases will be difficult to diagnose in any but a probabilistic fashion” (p. xxii)

Caveats Acknowledged by DSM-IV “The specific diagnostic criteria included in DSM-IV are meant to serve as guidelines to be informed by clinical judgement and are not meant to be used in a cookbook fashion.” (p. xxiii) “It is precisely because impairments, abilities, and disabilities vary widely within each diagnostic category that assignment of a particular diagnosis does not imply a specific level of impairment or disability.” (p. xxiii)

Caveats Acknowledged by DSM-IV “Nonclinical decision makers should also be cautioned that a diagnosis does not carry any necessary implication regarding the causes of the individual’s mental disorder or its associated impairments.” (p. xxiii) “Moreover, the fact that an individual’s presentation meets the criteria for a DSM-IV diagnosis does not carry any necessary implication regarding the individual’s degree of control over the behaviors that may be associated with the disorder.” (p. xxiii)

Multiaxial Classification Axis I - All categories except personality disorders and mental retardation Axis II - Long-term disturbances Axis III - Medical conditions believed to be relevant to the mental disorder in question Axis IV - Psychosocial and behavioral problems which may contribute to the disorder Axis V - Current level of adaptive functioning

Criticisms of Psychiatric Diagnosis Categorization leads to loss of information Categorical vs. Dimensional Classification Diagnoses have negative effects on those labeled Reliability of Diagnosis Validity of Diagnostic Categories Ignores Contextual and Cultural Considerations

Disorders in the DSM Disorders of infancy, childhood, or adolescence Delirium, dementia, and other cognitive disorders Schizophrenia and other psychotic disorders Mood disorders Mental retardation Learning disorders Autistic disorders Alzheimer’s disease Schizophrenia Delusional disorder Depressive disorder Bipolar disorder

Disorders in the DSM Anxiety disorders Eating disorders Personality disorders Substance related disorders Obsessive-compulsive PTSD Phobias Anorexia nervosa Bulimia nervosa Antisocial personality Paranoid personality Substance abuse Substance dependence

Disorders in the DSM

Major Depressive Disorder Five or more of the following: – Depressed mood most of the day, nearly every day – Markedly diminished interest or pleasure in all, or almost all, activities most of the day – Significant weight loss when not dieting or gaining weight or decrease in appetite – Insomnia or hypersomnia nearly every day – Psychomotor agitation or retardation nearly every day – Fatigue or loss of energy nearly every day – Feelings of worthlessness or excessive or inappropriate guilt nearly every day

Bipolar I Disorder Episodes of mania or mixed episodes that include symptoms of both mania and depression. Three of the following (four if mood is irritability) – Increase in activity level - at work, socially, or sexually – Unusual talkativeness, rapid speech – Flight of ideas or subjective impression that thoughts are racing – Less than the usual amount of sleep needed – Inflated self-esteem, belief that one has special powers, talents, abilities – Distractibility; attention easily diverted – Excessive involvement in risky activities

Evaluation of Cognitive Theory Depressed people judge themselves in biases ways Depressed people demonstrate the cognitive biases which Beck outlines Negative thinking decreases after treatment Although pessimistic, depressed people sometimes are actually more accurate than normal (e.g., judging probability of success) Whether depression is the result of cognitive biases or vice versa is not clear

Obsessive-Compulsive Disorder Persistent and uncontrollable thoughts or compulsion to repeat certain acts again and again, causing significant distress and interference with everyday functioning Obsessions - intrusive and recurring thoughts, impulses, and images that come unbidden to the mind and appear irrational and uncontrollable to the client Compulsion - repetitive behavior or mental act that the person is driven to perform to reduce the distress caused by obsessive thoughts or to prevent some calamity

Posttraumatic Stress Disorder (PTSD) An extreme response to a severe stressor, including increased anxiety, avoidance of stimuli associated with the trauma, and a numbing of emotional responses. The etiology in partially assumed in the definition - traumatic event(s) Distinguished from Acute Stress Disorder in DSM-IV

Major Symptoms of PTSD Reexperiencing the traumatic event - nightmares, difficulty during “anniversaries,” upset by stimuli associated with the event (e.g., thunder) Avoidance of stimuli associated with the event or numbing of responsiveness - decreased interest in others, estrangement Symptoms of increased arousal - insomnia, low concentration, exaggerated startle response

DSM-IV Criteria For Specific Phobia Marked or persistent fear that is excessive or unreasonable, cued by a specific object or situation Exposure to the phobic stimulus invariably provokes an immediate anxiety response The person realizes the fear is excessive or unreasonable (except in children) The phobic situation is avoided or endured with intense distress Phobia interferes with the person’s functioning If under 18 years - duration > 6 months

Treatment of Phobias Systematic Desensitization - in vivo exposure an important addition Cognitive Approaches - there is no evidence that eliminating irrational beliefs alone, without exposure, reduces phobias Biological Approaches - anxiolytics - benzodiazepines are addicting and produce severe withdrawal syndrome - relapse common

Schizophrenia Characteristic Symptoms: Two or more of the following, each present for a significant portion of time during a 1-month period (or less if successfully treated): – delusions – hallucinations – disorganized speech (e.g., frequent derailment or incoherence) – grossly disorganized or catatonic behavior – negative symptoms, i.e., affective flattening, alogia, or avolition Social/occupational dysfunction Continuous signs for 6 months, at least 1 month of symptoms

Categories of Schizophrenia Disorganized Schizophrenia - speech is disorganized and difficult to follow. Behavior is disorganized and not goal directed Catatonic Schizophrenia - catatonic symptoms Paranoid Schizophrenia - delusions of persecution, grandiose delusions, delusional jealousy, ideas of reference Undifferentiated – behavior doesn’t fit neatly into any of the above types