CLINICAL-REVIEWER

Defining Normality and Abnormality

Much practice and research conducted by clinical psychologists focuses on abnormality, also known as mental disorders, psychiatric diagnoses, or psychopathology. Clinical psychologists become familiar with definitions of various forms of abnormal behavior and its differences from normal behavior.

What Defines Abnormality?

Mental health professionals have proposed various criteria for defining abnormal behavior, including:

  • Personal Distress: e.g. severe depression, panic disorder, where individuals experience intense suffering and distress perceived as abnormal by society.

  • Deviance from Cultural Norms: e.g. cases of schizophrenia, where behaviors may significantly diverge from cultural expectations or norms.

  • Statistical Infrequency: e.g. rarer disorders like dissociative identity disorder, where behaviors or symptoms are statistically uncommon in the general population.

  • Impaired Social Functioning: e.g. social phobia, antisocial personality disorder, where individuals experience difficulties in social interactions or maintaining relationships due to their symptoms.

Jerome Wakefield's Theory: Harmful Dysfunction

This groundbreaking theory defines mental disorders as significant impairments that are both harmful and dysfunctional.

  • Harmful: Based on societal norms, behaviors that lead to perceived negative impact on well-being. These behaviors can cause undesirable social consequences and may lead to suffering or dissatisfaction within the individual.

  • Dysfunctional: Refers to the failure of a mental mechanism to perform its natural evolutionary function. This indicates that aspects of mental health can be understood through both scientific and social lenses and emphasizes the importance of biological processes in mental health issues while also considering the role of environment and experience.

WHO Defines Abnormality?

The definitions of abnormality are debated among academics and researchers due to the complex nature of mental health.

DSM (Diagnostic Statistical Manual of Mental Disorders):

This manual serves as a primary diagnostic guide for mental health professionals.

DSM-5 Definition of Mental Disorder

Described as a clinically significant disturbance in cognition, emotion regulation, or behavior indicating dysfunction in mental functioning, usually associated with distress or disability, indicating that the disorder has substantial impact on daily functioning, thereby qualifying it as a mental disorder. The definition emphasizes the importance of a holistic view, focusing not solely on symptoms but also on the impact on the individual's life.

Task Force Contributors

Comprising mainly of leading researchers in psychopathology, primarily psychiatrists, with fewer psychologists and nonmedical professionals involved. It's essential to note that the contributors' backgrounds significantly shape the DSM. This diversity is intended to minimize bias and enhance the reliability of diagnoses, reflecting a wider range of perspectives on mental health.

History of DSM

  • First Edition (DSM-I): Published in 1952 by white male psychiatrists, setting the foundation for modern psychiatric diagnosis, primarily focusing on psychoses and neuroses without significant cultural considerations.

  • Recent Efforts: Includes more diverse contributors in the development of the latest editions, such as psychologists, social workers, and even individuals with lived experiences of mental health issues, aiming to address historical biases and broaden perspectives in defining mental health issues. This also includes extensive consultation with various cultural and advocacy groups to represent a wider range of experiences and ensure cultural competence in diagnosis.

Diagnosis and Classification of Mental Disorders: A Brief History

Early Theorists and DSM Development

  • Hippocrates: Emphasized natural causes of mental illness, correlating symptoms with bodily fluid imbalances. His perspective shifted a considerable amount of early thought towards a medical model of understanding, moving away from punitive views of mental illness as it was more commonly seen in earlier societies.

  • Philippe Pinel: Proposed early categorizations of mental disorders, emphasizing conditions like melancholia, mania, and dementia, which laid the groundwork for future classifications. He advocated for more humane treatment methods, focusing on moral treatment rather than confinement.

  • Emil Kraepelin: Identified manic-depressive psychosis and dementia praecox (now known as schizophrenia), establishing clear criteria for diagnosing various mental illnesses. His work significantly influenced later DSM editions due to his systematic approach to categorizing mental disorders based on observable symptoms and clinical observations, which was revolutionary at the time.

DSM Timeline

  • DSM-I: Published in 1952.

  • DSM-II: Revised in 1968, categorizing disorders into basic classifications, distinguishing between psychoses, neuroses, and character disorders. Major criticism arose during this time regarding the lack of empirical evidence to support many diagnoses included, highlighting a need for improvement.

  • DSM-III: Introduced a multiaxial assessment approach in 1980, considering multiple aspects of a person's life in diagnosis, including medical, psychological, and social factors, which improved diagnostic accuracy and sensitivity. This marked a significant turning point toward a more scientific approach to psychiatric disorders.

  • DSM-5: Released in May 2013, featuring substantial revisions after two decades of research and user feedback, directed by David Kupfer and Darrel Regier. The process leading up to its release involved rigorous field trials and peer-reviewed studies aimed at refining the definitions and criteria for disorders.

DSM-5 Features Development and Field Trials

Different workgroups reviewed disorders and proposed necessary revisions, validated by the Scientific Review Committee and comprehensive field trials, ensuring the inclusion of updated practices and evidence in the diagnosis of mental disorders. Field trials provided clinical validation of new and revised diagnoses, ensuring they were clinically useful and reliable.

New Format

The DSM-5 allows for frequent minor updates instead of requiring complete revisions, facilitating quicker incorporation of research findings into clinical practice.

New Disorders Introduced

  • Premenstrual Dysphoric Disorder (PMDD): Recognized as severe PMS significantly affecting life functionality. PMDD involves emotional and physical symptoms that greatly interfere with daily life, and its inclusion highlights the growing recognition of women's health issues.

  • Disruptive Mood Dysregulation Disorder (DMDD): Characterized by frequent temper tantrums in children, emphasizing the emotional dysregulation component, and aims to prevent overdiagnosing bipolar disorder in children which has been contentious in psychological communities.

  • Binge Eating Disorder (BED): Involves episodes of binge eating without compensatory behaviors, addressing the need for distinct recognition of eating disorders, particularly in light of the rising rates of obesity and associated health risks.

  • Mild Neurocognitive Disorder: Involves modest decline in cognitive functions, accounting for early stages of cognitive deterioration and allowing for earlier identification and potential intervention strategies.

Additional New Disorders

  • Somatic Symptom Disorder: Involves excessive focus on bodily symptoms which may not have a medical explanation, often leading to significant distress. This recognizes the intersection between mental and physical health, promoting an integrated approach to treatment.

  • Hoarding Disorder: Defined by the difficulty in discarding possessions, leading to significant impairment and distress in daily functioning. This disorder highlights the complexities of mental health as it often co-occurs with anxiety and obsessive-compulsive symptoms, necessitating targeted interventions.

Revised Disorders in DSM-5

  • Dropped the "bereavement exclusion" for major depression, reducing prior restrictions in diagnosing major depression after loss, which has faced criticism as it limited essential treatment opportunities for people undergoing grief.

  • Consolidated various autism-related disorders into Autism Spectrum Disorder, providing a more nuanced understanding of the role of genetics and environment in these conditions, while updating criteria regarding ADHD focusing on age of symptom onset and symptom requirements.

Structural Changes in Disorders

  • Substance Use Disorder: Combined substance abuse and dependence, reflecting modern understanding of addiction as a spectrum. This change emphasizes the continuous nature of substance-related issues, allowing for tailored treatment approaches.

  • Intellectual Disability: Renamed from mental retardation, consolidating learning disabilities into a single diagnosis focusing on functioning rather than restrictive labels, which aims at reducing stigma and improving educational and social supports.

  • Obsessive-Compulsive Disorder: Placed into its category, recognizing its unique symptoms and treatment needs. The distinction aids clinicians in developing specialized treatment strategies and assists in education about the disorder.

  • Split Mood Disorders into Depressive Disorders and Bipolar and Related Disorders, reflecting the distinct natures of these conditions and highlighting the necessity for varied therapeutic interventions for different patient profiles.

Controversies and Criticisms of DSM-5

Concerns include diagnostic over-expansion, the rising cost of treatment based on diagnosis, which may limit access to care for many, the transparency of the DSM development process, the presence of cultural biases that might influence diagnosis, and worries about the implications of labelling and stigmatization. Critics often argue for a more inclusive approach to understanding mental health that considers social determinants and the lived experiences of those affected, rather than relying solely on standardized categorizations.