Chapter 3 – Classification and Diagnosis Copyright © 2014 John Wiley & Sons, Inc. All rights...

Chapter 3 – Chapter 3 – Classification Classification and Diagnosisand Diagnosis

Copyright © 2014 John Wiley & Sons, Inc. Copyright © 2014 John Wiley & Sons, Inc. All rights reserved.All rights reserved.

How do we understand the How do we understand the individual person? individual person?

Each mental patient is unique and presents a Each mental patient is unique and presents a combination of genetic factors, life experiences, combination of genetic factors, life experiences, and current circumstances that affect behavior and current circumstances that affect behavior

We need to assess individual factors but at the We need to assess individual factors but at the same time compare this patient’s behavior to a same time compare this patient’s behavior to a general body of knowledge based on the general body of knowledge based on the investigation of may people with similar investigation of may people with similar symptomssymptoms

We search for common patterns of behavior We search for common patterns of behavior that would enable us to assign this patient to a that would enable us to assign this patient to a category of mental illness .That is, to classify. category of mental illness .That is, to classify.


ClassificationClassification: a way for scientists to organize, : a way for scientists to organize, describe, and relate the subject matter of their describe, and relate the subject matter of their disciplinediscipline

ValidityValidity: whether a classification scheme is : whether a classification scheme is accurately capturing realityaccurately capturing reality

UtilityUtility: how useful a classification scheme is : how useful a classification scheme is Diagnosis systemDiagnosis system: a classification based on : a classification based on

rules used to organize and understand rules used to organize and understand diseases and disordersdiseases and disorders

When the rules are applied to the symptoms of When the rules are applied to the symptoms of one person we get a diagnosis for the one person we get a diagnosis for the symptoms in this person symptoms in this person

Important Aspects of a Important Aspects of a Classification SchemeClassification Scheme


Categorical approachCategorical approach: an object is determined to : an object is determined to be a member of a category or not (e.g., depressed be a member of a category or not (e.g., depressed or not depressed);or not depressed); Qualitative Qualitative difference difference between the various categories between the various categories

Dimensional approachDimensional approach: an object differs in degree : an object differs in degree from others – a continuum (e.g., mildly depressed, from others – a continuum (e.g., mildly depressed, moderately depressed, severely depressed)moderately depressed, severely depressed)

Prototype modelPrototype model: members of a category may : members of a category may differ in degree to which they represent a common differ in degree to which they represent a common example (used in DSM); this is a quantitative example (used in DSM); this is a quantitative approach – members differ in approach – members differ in quantityquantity- how - how much the have of the dimension (e.g. depression) much the have of the dimension (e.g. depression)

Important Aspects of a Important Aspects of a Classification SchemeClassification Scheme


An examples of a Dimensional An examples of a Dimensional Approach Approach

Thomas Achenbach identified two Thomas Achenbach identified two broad dimensions of behaviors in broad dimensions of behaviors in children:children:

Externalizing and Internalizing Externalizing and Internalizing The child’s behavior can be The child’s behavior can be

described on the basis of the described on the basis of the intensity of the externalizing or intensity of the externalizing or internalizing behaviorsinternalizing behaviors


The Purpose of a Diagnostics The Purpose of a Diagnostics System for Mental Disorders System for Mental Disorders

(Exhibit 3.1 p. 67) (Exhibit 3.1 p. 67)

Provide a description of the patient’s Provide a description of the patient’s conditioncondition

Reflect the best scientific knowledge of Reflect the best scientific knowledge of psychopathology psychopathology

Provide a common language for mental Provide a common language for mental health professional and also patientshealth professional and also patients

Indicate possible causes (etiology)Indicate possible causes (etiology) Indicate possible outcomes (prognosis)Indicate possible outcomes (prognosis) Provide guidance on co-existenceProvide guidance on co-existence Provide guidance on treatment option Provide guidance on treatment option


What is abnormal? Many factors need to What is abnormal? Many factors need to be considered including:be considered including:– The cultural and societal contextThe cultural and societal context– Whether there is distress or discomfortWhether there is distress or discomfort– Whether the problem is harming othersWhether the problem is harming others– How common the problem isHow common the problem is– How much it is interfering with a person’s How much it is interfering with a person’s

ability to function ability to function – If it is common for that person’s If it is common for that person’s

developmental stage (developmental developmental stage (developmental psychopathology)psychopathology)

Defining Abnormal BehaviorDefining Abnormal Behavior


No diagnosis is based on a single No diagnosis is based on a single symptomsymptom

DSM-IV-TR defines disorder in a DSM-IV-TR defines disorder in a complicated fashion includingcomplicated fashion including– Symptoms associated with distress or Symptoms associated with distress or

impairment/disabilityimpairment/disability– Increased risk of sufferingIncreased risk of suffering– Culturally atypical Culturally atypical – Not just deviant behavior (unless there is Not just deviant behavior (unless there is

also dysfunction)also dysfunction)

Diagnosis and Defining Diagnosis and Defining DisorderDisorder


Developmental Developmental Psychopathology Psychopathology

Common in Child Assessment Common in Child Assessment

• Developmental psychopathology is an Developmental psychopathology is an approach to describing and studying approach to describing and studying disorders of childhood and disorders of childhood and adolescence in a way that stresses the adolescence in a way that stresses the importance of developmental importance of developmental processes and tasksprocesses and tasks

• One needs to be familiar with the One needs to be familiar with the sequence and the timing of sequence and the timing of developmental milestones developmental milestones


Developmental Developmental Psychopathology Psychopathology

(cont-d) (cont-d)

To understand maladaptive To understand maladaptive behavior, one must view it in behavior, one must view it in relation to what is considered relation to what is considered normativenormative

Abnormal development involves Abnormal development involves continuities and discontinuities, with continuities and discontinuities, with both quantitative and qualitative both quantitative and qualitative changes in patterns of behavior over changes in patterns of behavior over timetime


Wakefield – Wakefield – Harmful DysfunctionHarmful Dysfunction: the : the problem must be clear and there must problem must be clear and there must be harm to person or othersbe harm to person or others

DyscontrolDyscontrol: impairment must be : impairment must be involuntary or not readily controlledinvoluntary or not readily controlled

Diagnosis criteria always include a Diagnosis criteria always include a cluster of symptoms (a syndrome) that cluster of symptoms (a syndrome) that co-occur co-occur

Diagnosis and Defining Diagnosis and Defining DisorderDisorder


Most all contemporary models are Most all contemporary models are biopsychosocial – but different theories biopsychosocial – but different theories represent different emphasesrepresent different emphases

Some models emphasize biological Some models emphasize biological aspects while others emphasize aspects while others emphasize psychological or social aspectspsychological or social aspects

Life stress modelLife stress model – important impact of – important impact of the number of life stressors on the the number of life stressors on the development of disordersdevelopment of disorders

The Development of DisordersThe Development of Disorders


First edition of DSM (1952) had fairly First edition of DSM (1952) had fairly vague terms and emphasized vague terms and emphasized psychodynamic contributions psychodynamic contributions

DSM-II (1968) was less DSM-II (1968) was less psychodynamically focused as psychodynamically focused as medications were more commonly being medications were more commonly being used used

DSM-III (1980) guided by Robert Spitzer, DSM-III (1980) guided by Robert Spitzer, was atheoretical (revision done in 1987)was atheoretical (revision done in 1987)– Focus on diagnostic criteria, multiaxial, Focus on diagnostic criteria, multiaxial,

increase in focus on reliabilityincrease in focus on reliability

The DSM Approach to The DSM Approach to Diagnosis: HistoryDiagnosis: History


DSM-IV (1994)DSM-IV (1994)– Further focus on reliabilityFurther focus on reliability– ‘‘Work groups’ worked on clusters of Work groups’ worked on clusters of

disordersdisorders– Text revision (diagnostic criteria Text revision (diagnostic criteria

unchanged) DSM-IV’TR’ completed in 2000unchanged) DSM-IV’TR’ completed in 2000 DSM-5 (2013) – Current Diagnostic DSM-5 (2013) – Current Diagnostic

ManualManual– Removed some categories and diagnoses, Removed some categories and diagnoses,

added others added others

The DSM Approach to The DSM Approach to Diagnosis: HistoryDiagnosis: History


DSM-5DSM-5– Defines a mental disorder as …”a syndrome Defines a mental disorder as …”a syndrome

characterized by characterized by clinically significantclinically significant disturbance in an individual’s cognition, disturbance in an individual’s cognition, emotion regulation, or behavior that reflects emotion regulation, or behavior that reflects a dysfunction in the psychological, biological, a dysfunction in the psychological, biological, or developmental processes underlying or developmental processes underlying mental functioning.”mental functioning.”

– Associated with distress or disabilityAssociated with distress or disability– Culturally expected response is not a mental Culturally expected response is not a mental

disorderdisorder

The DSM Approach to The DSM Approach to DiagnosisDiagnosis


DSM-5 Some ChangesDSM-5 Some Changes– Many disorders are now grouped differently Many disorders are now grouped differently

(e.g., depression, anxiety, and somatic (e.g., depression, anxiety, and somatic disorders are grouped as internalizing disorder)disorders are grouped as internalizing disorder)

– Personality disorders, childhood disorders are Personality disorders, childhood disorders are not separated from other disorders as in not separated from other disorders as in previous versions previous versions

– Controversy in many of the changes, including Controversy in many of the changes, including how reliable they are, what defines a diagnosis, how reliable they are, what defines a diagnosis, and what diagnoses were removed/changedand what diagnoses were removed/changed



Importance of considering cultureImportance of considering culture– Information in the text on cultural variationInformation in the text on cultural variation– Cultural bound syndromesCultural bound syndromes– Diagnosis should not occur if symptoms are Diagnosis should not occur if symptoms are

culturally typicalculturally typical– Diagnosis must be done in a culturally Diagnosis must be done in a culturally

sensitive contextsensitive context– Section on cultural formulationSection on cultural formulation

Attending to cultural identityAttending to cultural identity Cultural explanations for disorderCultural explanations for disorder Cultural relationships with client and clinicianCultural relationships with client and clinician


Copyright © 2014 John Wiley & Sons, Inc. All rights reserved.Copyright © 2014 John Wiley & Sons, Inc. All rights reserved.

Comorbidity: when a person receives Comorbidity: when a person receives two diagnoses at oncetwo diagnoses at once– DSM attempts to decrease the likelihood of DSM attempts to decrease the likelihood of

this with several exclusionary rulesthis with several exclusionary rules– However, comorbidity is very common in However, comorbidity is very common in

the DSM (previous estimates >40%)the DSM (previous estimates >40%) Diagnoses do not account for normal Diagnoses do not account for normal

reactions to life stressors (e.g., divorce, reactions to life stressors (e.g., divorce, terminal illness) terminal illness)

The DSM Approach to The DSM Approach to Diagnosis Diagnosis Problems/LimitationsProblems/Limitations


Diagnostic criteria seem to include too much Diagnostic criteria seem to include too much of the population (sometimes 25-30% of the of the population (sometimes 25-30% of the population)population)

Although better than the earlier versions DSM Although better than the earlier versions DSM diagnoses are not as reliable as hoped (may diagnoses are not as reliable as hoped (may be due to reliance on categories)be due to reliance on categories)

Heterogeneity of symptom profiles is Heterogeneity of symptom profiles is problematicproblematic

Polythetic nature of disorders: same diagnosis Polythetic nature of disorders: same diagnosis can be applied to similar can be applied to similar andand different different symptomssymptoms



Validity of some disorders is Validity of some disorders is questionable (i.e., that the diagnosis is questionable (i.e., that the diagnosis is a discrete entity)a discrete entity)

Current research indicates that some Current research indicates that some disorders may be both a category and a disorders may be both a category and a continuum (e.g., depression)continuum (e.g., depression)

Resilience is often not included in Resilience is often not included in understanding disorders, yet is a understanding disorders, yet is a common aspect of human functioningcommon aspect of human functioning



International Statistical Classification of International Statistical Classification of Diseases and Related Health Problems Diseases and Related Health Problems (ICD-10) – developed by World Health (ICD-10) – developed by World Health Org.Org.– Mental and behavioral disorders subsection Mental and behavioral disorders subsection

(compatible with the DSM-IV)(compatible with the DSM-IV)– Companion “International Classification of Companion “International Classification of

Functioning, Disability and Health (ICF)” Functioning, Disability and Health (ICF)” focused on overall functioning and healthfocused on overall functioning and health

Achenbach System of Empirically Based Achenbach System of Empirically Based Assessment – internalizing/externalizing Assessment – internalizing/externalizing problemsproblems

Other Classification Other Classification SchemesSchemes


Chapter 3 – Classification and Diagnosis Copyright © 2014 John Wiley & Sons, Inc. All rights...

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