Psychopathology and the Psychopathology and the DSMDSM

Characteristics of A Useful Characteristics of A Useful Diagnostic SystemDiagnostic System

Facilitates CommunicationPossesses Etiological ValidityProvides Reliable Information on

Disabilities, Abilities, Functional Impairments, etc.

Guides Research (homogeneous groups)Informs Treatment DecisionsPredicts Clinical Course

History of Psychiatric History of Psychiatric DiagnosisDiagnosis

End of the 19th century - diversity of classifications a major problem

1939 - WHO adds mental disorders to International list of Causes of Death (ICD)

1948 - ICD covers abnormal behavior1952 - American Psychiatric Association

Publishes the DSM - I1969 - WHO publishes new classification

system. APA follows with DSM-II

History of Psychiatric History of Psychiatric DiagnosesDiagnoses

1980 - APA publishes extensively revised DSM-III, followed by a somewhat revised DSM-IIIR.

1994 - 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 Caveats Acknowledged by DSM-IVDSM-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 Caveats Acknowledged by DSM-IVDSM-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 Caveats Acknowledged by DSM-IVDSM-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 byCaveats Acknowledged by DSM-IV 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 ClassificationMultiaxial Classification

Axis I - All categories except personality disorders and mental retardation

Axis II - Long-term disturbancesAxis III - Medical conditions believed to be

relevant to the mental disorder in questionAxis IV - Psychosocial and behavioral

problems which may contribute to the disorderAxis V - Current level of adaptive functioning

Criticisms of Psychiatric Criticisms of Psychiatric DiagnosisDiagnosis

Categorization leads to loss of informationCategorical vs. Dimensional ClassificationDiagnoses have negative effects on those

labeledReliability of DiagnosisValidity of Diagnostic CategoriesIgnores Contextual and Cultural

Considerations

Disorders in the DSMDisorders 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 DSMDisorders 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 DSMDisorders in the DSM

Major Depressive DisorderMajor 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 DisorderBipolar 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 Evaluation of Cognitive TheoryTheory

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 Obsessive-Compulsive DisorderDisorder

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 Posttraumatic Stress Disorder (PTSD)(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 PTSDMajor Symptoms of PTSDReexperiencing 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 DSM-IV Criteria For Specific PhobiaPhobia

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 PhobiasTreatment 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

SchizophreniaSchizophreniaCharacteristic 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 dysfunctionContinuous signs for 6 months, at least 1 month

of symptoms

Categories of SchizophreniaCategories of SchizophreniaDisorganized 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