DIAGNOSING PSYCHOLOGICAL DISORDERS AB Psych - Chapter 3

Individual (idiographic) approach

closely observe behavior, cognitive processes, mood; use semistructured interviewing, behavioral assessment, psychological tests → tells what is unique about the person.

• Used to determine what is unique about an individual’s personality, cultural background, or circumstances.

• Allows tailoring of treatment to the person.

General (nomothetic) approach

determine how the person resembles others with similar problems; find applicable information from past cases (onset, influential factors, duration, treatment needs, effective treatments).

• Used to take advantage of accumulated information on a particular problem or disorder.

• Determine a general class of problems to which the presenting problem belongs.

• Identify a specific psychological disorder or general class/grouping of problems (e.g., personality profile on MMPI).

DSM-5

official system in the U.S., widely used throughout the world; closely related to ICD-10.

• Clinicians use DSM-5 to identify a specific psychological disorder in making a diagnosis.

ICD-10

International Classification of Diseases, 10th edition (World Health Organization, 1992).

Nosology

 taxonomic system applied to psychological/medical phenomena or other clinical areas.

Approaches to Classification

• Classical (Pure) Categorical Approach

• Dimensional Approach

• Prototypical Approach

Classical (Pure) Categorical Approach

• Originates from Emil Kraepelin and biological tradition.

• Assumes every diagnosis has a clear underlying pathophysiological cause.

• Each disorder is unique; only one set of causative factors; no overlap.

• Requires meeting all defining criteria to be diagnosed.

• Useful in medicine (clear cause → specific treatment).

• Inappropriate for complexity of psychological disorders; most involve interaction of biological, psychological, and social factors.

Dimensional Approach

• Notes variety of cognitions, moods, behaviors and quantifies them on a scale.

• Creates an emotional functioning profile (e.g., anxious 10, depressed 5, manic 2).

• Applied in the past to psychopathology, particularly personality disorders.

• Limitations: disagreement on number of dimensions needed (from 1 to as many as 33).

Prototypical Approach

• Combines features of categorical and dimensional approaches.

• Identifies essential characteristics for classification, allows nonessential variations.

• Requires certain number of prototypical criteria plus some additional criteria.

• Boundaries between categories are “fuzzy”; symptoms may apply to more than one disorder.

• Fits better with current knowledge of psychopathology; relatively user-friendly.

• Example: DSM-5 criteria for major depressive episode—must have depressed mood or loss of interest plus at least four of remaining eight symptoms; individuals may meet criteria with different symptom combinations.

Reliability

• Classification should describe specific subgroups of symptoms clearly evident and readily identified by experienced clinicians.

• Two clinicians interviewing the same patient on the same day should see the same set of behaviors and emotions.

• If disorder is not apparent to both, diagnoses might represent bias.

• Unreliable classification systems are subject to bias by clinicians

Unreliability of personality disorders

• are one of the most unreliable categories.

• Morey & Ochoa (1989): 291 mental health professionals described a personality disorder patient they had seen; compared clinician diagnosis with objective criteria.

• More reliable nosology → less likely for bias to creep in.

• Found substantial bias:

• Less experienced or female clinicians diagnosed borderline personality disorder more often than criteria indicated.

• More experienced or male clinicians diagnosed it less often.

• White, female, or poor patients diagnosed more often than criteria indicated.

Validity

System of nosology must be valid.

Construct validity

signs and symptoms chosen as criteria are consistently associated and differ from other categories.

Predictive validity

iagnosis tells clinician likely course of disorder and likely effect of treatment.

Criterion validity

outcome is the criterion for judging the usefulness of the diagnostic category.

Content validity

criteria for diagnosis should reflect the way most experts think of the disorder.

familial aggregation

the extent to which the disorder would be found among the patient’s relatives

DIAGNOSIS BEFORE 1980

• Long past but recent history.

• Observations of symptoms (depressed, phobic, psychotic) date to earliest human records.

• As late as 1959 → at least nine systems worldwide; only three listed “phobic disorder” separately.

• Early classification arose from biological tradition, especially Kraepelin.

• Identified schizophrenia (originally “dementia praecox”) and bipolar disorder (originally “manic depressive psychosis”).

• Described organic brain syndromes.

• Kraepelin’s belief: psychological disorders are biological disturbances → early emphasis on classical categorical strategies.

• 1948: WHO added mental disorders to ICD-6.

• 1952: DSM-I published.

• Late 1960s: nosology systems began influencing professionals.

• 1968: DSM-II published.

• 1969: ICD-8 published (identical to DSM-II).

• Early systems lacked precision, relied on unproven theories, and had little reliability

• 1970s: many countries (e.g., France, Russia) still had separate systems; same disorders labeled/interpreted differently

DSM-III and DSM-III-R

• Landmark under Robert Spitzer.

• Two major changes:

  • Atheoretical approach; precise descriptions rather than theories of etiology.

  • Specificity/detail in criteria → study of reliability & validity possible.

• Phobia given its own category within “anxiety disorders” instead of “neurosis.”

• Multiaxial format → broad consideration of the whole individual.

• More clinicians worldwide used (Diagnostic and Statistical Manual)  DSM-III-R than ( International Classification of Diseases)  ICD.

DSM-IV (1994) & DSM-IV-TR (2000)

• Goal: compatibility with ICD-10 (1992).

• Changes based on sound scientific data, not just consensus.

• 12 independent field trials for reliability/validity.

• Eliminated distinction between organically vs. psychologically based disorders.

• DSM-IV-TR: updated research literature, minor criteria changes, clarified issues.

DSM-5 (2013)

• Collaboration with ICD-11 workgroups.

• Mostly unchanged from DSM-IV; some new disorders/reclassifications.

• Three sections:

  • Intro & use.

  • Disorders.

  • Conditions for further research.

• Dimensional axes for severity/intensity/frequency/duration.

• PTSD severity example: NSESSS-PTSD (9-item self-report).

• Cross-cutting symptom measures (e.g., anxiety, depression, sleep problems).

• Categories remain, but dimensions add clinical information.

• Impairment essential for diagnosis: must cause “clinically significant distress or impairment.”

• Subthreshold if symptoms present but not impairing enough.

Social & Cultural Considerations

• DSM-IV introduced cultural formulation; DSM-5 retains.

• “Culture” = values, knowledge, practices from ethnic/religious/social groups.

• DSM-5 Cultural Formulation Interview sample questions:

  • Primary cultural reference group; acculturation/language mastery.

  • Use of old-country terms (e.g., ataques de nervios).

  • Cultural views of disability; family/social/religious supports.

• No research yet supporting these guidelines; more work needed for cultural sensitivity.

Criticisms of DSM-5

• Fuzzy categories → comorbidity common.

• Reliability emphasized over validity.

• Perpetuates flawed definitions from past decades.

• Reification of categories; must avoid forcing borderline cases into one category.

Labeling & Stigma

• Labeling → stereotype, prejudice, reduced opportunities.

• Past intellectual disability labels (“moron,” “imbecile,” “idiot”) became pejorative → replaced by “intellectual disability” (mild/moderate/severe/profound).

• Negative meanings not inevitable if diagnosis relayed compassionately.

• Stigmatization of mental disorders is increasing.

Important: terms describe patterns of behavior, not the person.

CREATING A DIAGNOSIS

• Mixed Anxiety-Depression

• PRE MENSTRUAL DYSPHORIC DISORDER (PMDD)

Mixed Anxiety-Depression

• Common in primary care settings: minor aches/pains (no physical basis), feeling uptight, down, anxious.

• Symptoms classic but not severe/frequent enough for existing anxiety or mood disorder.

• Thresholds important to ensure only clearly impaired individuals qualify.

• Concern: legal/policy implications, financial reimbursement, disability payments.

• Klerman & Weissman (1989): impairment worse than many chronic medical conditions; high burden on health-care system.

• ICD-10 created a category but without definition/criteria.

• Study goals:

  1. Can careful interviews identify cases, or are criteria for existing disorders overlooked?

  2. More prevalent in primary care than outpatient mental health?

  3. What set of criteria best identifies the disorder?

PRE MENSTRUAL DYSPHORIC DISORDER (PMDD)

• Severe/incapacitating emotional reactions in the late luteal phase.

• Arguments for: suffering/impairment warrant care/support; inclusion promotes research.

• Arguments against: little scientific info; risk of stigmatizing normal endocrinological stage; parallels to “hysteria”; possible male counterpart; maybe endocrinological/gynecological not psychiatric.

• DSM-III-R: placed in appendix; named late luteal phase dysphoric disorder (LLPDD) to differentiate from PMS.

• Post-DSM-III-R: rapid research growth; PMS = 20–40% prevalence (mild), LLPDD = ~4.6% (severe/incapacitating); many without other psychological disorder; biological abnormalities; promising treatments.

• Still concerns: stigmatization, cultural bias, legal misuse (e.g., custody cases).

• Some women embrace label; others reject psychiatric framing.

• 1994 DSM-IV: retained in appendix; renamed PMDD (symptoms not exclusive to luteal phase).

• Post-1994: thousands of papers; prevalence: disabling symptoms 2–5%, moderate 14–18%; treatment guidelines (American College of Obstetricians and Gynecology, 2002); ongoing research.

• Difficulty: distinguish PMDD from premenstrual exacerbations of other disorders.

• Hartlage et al. (2012) method: symptoms absent/mild postmenstrually; some symptoms distinct from mood disorder.

• Evidence suggests PMDD is a mood disorder.

DSM-5: included as a distinct psychological disorder in the mood disorders chapter.