Transcript Psychopathology and the DSM

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
 1939 - WHO adds mental disorders to
International list of Causes of Death (ICD)
 1948 - ICD covers abnormal behavior
 1952 - American Psychiatric Association
Publishes the DSM - I
 1969 - WHO publishes new classification
system. APA follows with DSM-II
History of Psychiatric
Diagnoses

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
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)
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Caveats Acknowledged by
DSM-IV
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“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
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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
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Delirium, dementia, and
other cognitive disorders
 Schizophrenia and other
psychotic disorders
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Mood disorders
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Mental retardation
Learning disorders
Autistic disorders
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Alzheimer’s disease
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Schizophrenia
Delusional disorder
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Depressive disorder
Bipolar disorder
Disorders in the DSM
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Anxiety disorders
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Eating disorders
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Personality disorders
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Substance related
disorders
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Obsessive-compulsive
PTSD
Phobias
 Anorexia nervosa
 Bulimia nervosa
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Antisocial personality
Paranoid personality
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Substance abuse
Substance dependence
Disorders in the DSM
Major Depressive Disorder
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Five or more of the following:
– Depressed mood most of the day, nearly every day
– Markedly diminished interest or pleasure in all, or almost
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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
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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
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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
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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
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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
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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
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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
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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):
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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