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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