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UNIT 2 CLASSIFICATION OF
PSYCHOPATHOLOGY: DSM IV TR
Structure 2.0 Introduction 2.1 Objectives 2.2 Meaning and Purpose of Classification of Psychopathology 2.2.1 Approaches to the Classification of Psychopathology 2.3 History of Classification of Psychopathology 2.3.1 Development of ICD 2.3.2 Classification of Mental Disorders in ICD- 2.4 Diagnostic and Statistical Manual of Mental Disorders (DSM) 2.4.1 A Brief History of DSM 2.4.2 Revisions of DSM 2.5 DSM-IV (TR): The Current Version of DSM 2.5.1 Multi-Axial Classifications 2.6 Evaluation of DSM-IV (TR) 2.7 Let Us Sum Up 2.8 Unit End Questions 2.9 Glossary 2.10 Suggested Readings
2.0 INTRODUCTION
Classification is the core of science. Therefore, classification systems are developed with which we could define or classify behaviour. Abnormal psychology is based on the assumption that behaviour is part of one category or disorder and not of another one. A thorough account of classification of mental disorders will be presented in this unit. First of all, we will discuss meaning, purposes and approaches of classification of mental disorders. This will be followed by a description of history of classification of mental disorders. We will then discuss widely used DSM-IV (TR), the current version of DSM. Finally, DSM-IV (TR) will be evaluated.
2.1 OBJECTIVES
After reading this unit, you will be able to: Explain meaning, purpose and approaches of classification of mental disorders; Present an account of history of classification of mental disorders; Explain ICD-10 for the classification of mental disorders; Understand the development of DSM as a system of classification of mental disorders;
Present an account of DSM-IV (TR); and Evaluate DSM-IV (TR).
2.2 MEANING AND PURPOSE OF
CLASSIFICATION OF PSYCHOPATHOLOGY
In order to classify the psychological disorders we need a classification system. The term classification refers to process to construct categories and to assign people to these categories on the basis of their attributes. Classification in scientific context refers to taxonomy. It also refers to nomenclature, which describes the names and labels that may make up a particular disorder such as schizophrenia or depression. Classification is at the heart of every science. If we cannot label and order objects or experiences or behaviours scientists could not communicate with one another and our knowledge will not advance. Without labelling and organising patterns of abnormal behaviour, researchers could not communicate their findings to one another, and progress toward understanding and decision about these disorders would come to a halt. Certain psychological disorders respond better to one therapy than another or to one drug than another. Classification also helps clinicians predict behaviour. Finally, classification helps researchers identify populations with similar patterns of abnormal behaviour. By classifying groups of people as depressed, for example, researchers might be able to identify common factors that help explain the origins of depression. Classification of psychopathology fulfils following five primary purposes:
- Communication
- Control
- Comprehension
- Distinction
- Prognosis/prediction
2.2.1 Approaches to the Classification of Psychopathology
Psychologists use three approaches or strategies to classify disorders: i) Categorical approach: It was Kraepelin, the first psychiatrist to classify psychological disorders from a biological or medical point of view. For Kraepelin in term of physical disorders, we have one set of causative factors which do not overlap with other disorders. We have one defining criteria, which everybody in the category or in the group should meet, e. g. Schizophrenia. After a category has been defined, an object is either a member of the category or it is not. A categorical approach to classification assumes that distinctions among members of different categories are qualitative. In other words, the differences reflect a difference in kind (quality) rather than a difference in amount (quantity). ii) Dimensional approach: A second strategy is a dimensional approach, in which we note the variety of cognitions, moods and behaviours with which the patient presents and quantify them on a scale. For example, on a scale of 1 to 10, a patient might be rated as severely anxious (10), moderately depressed (5), and mildly manic (2) to create a profile of emotional functioning (10, 5, 2). Although dimensional approaches have been applied to psychopathology, they are relatively Classification of Psychopathology: DSM IV TR
for future research. A major international conference on classification and diagnosis was held in Copenhagen, Denmark, in 1982 to review the recommendations that emerged from these workshops and to outline a research agenda and guidelines for future work. Several major research efforts were undertaken to implement the recommendations of the Copenhagen conference. All these efforts resulted in the publication of ICD-10 in 1992 in which in chapter V (F) pertained to the classification of mental disorders explaining their inclusion and exclusion terms.
2.3.2 Classification of Mental Disorders in ICD-
A brief description of classification of mental disorders as per ICD-10 is given below: F00-F09: Organic, including symptomatic, mental disorders: Dementia, delirium, organic. F10-F19: Mental and behavioural disorders due to use of psychoactive substances: Alcohol, cocaine and tobacco. F20-F29: Schizophrenia, schizotypal and delusional disorders. F30-F39: Mood (affective) disorders: Manic, bipolar, depressive. F40-F48: Neurotic, stress-related and somatoform disorders: Phobia, OCD, adjustment, dissociative. F50-F59: Behavioural syndromes associated with physiological disturbances and physical factors: Eating, sleep, sexual disorders. F60-F69: Disorders of personality and behaviour in adult persons: Specific, impulse disorder, gender identity. F70-F79: Mental retardation F80-F89: Disorders of psychological development: Speech and language, pervasive development. F90-F98: Behavioural and emotional disorders with onset usually occurring in childhood and adolescence: Hyperkinetic, conduct, tic. F-99: Unspecified mental disorders. Self Assessment Questions
- Explain meaning of classification of psychopathology. ..................................................................................................................... ..................................................................................................................... ..................................................................................................................... .....................................................................................................................
- Describe the purpose of classification of psychopathology. ..................................................................................................................... ..................................................................................................................... ..................................................................................................................... Classification of Psychopathology: DSM IV TR
Foundations of Psychopathology .....................................................................................................................
- Give an account of approaches to the classification of psychopathology. ..................................................................................................................... ..................................................................................................................... ..................................................................................................................... .....................................................................................................................
- Explain the initial efforts of classification of psychopathology. ..................................................................................................................... ..................................................................................................................... ..................................................................................................................... .....................................................................................................................
- Describe the importance of ICD in classification of psychopathology. ..................................................................................................................... ..................................................................................................................... ..................................................................................................................... .....................................................................................................................
- Present an account of classification of mental disorders prescribed in ICD-10. ..................................................................................................................... ..................................................................................................................... ..................................................................................................................... .....................................................................................................................
2.4 DIAGNOSTIC AND STATISTICAL MANUAL OF
MENTAL DISORDERS (DSM)
The Diagnostic and Statistical Manual of Mental Disorders, published by the American Psychiatric Association, is the handbook used most often in diagnosing mental disorders in the United States and other countries.
2.4.1 A Brief History of DSM
Need of statistical information regarding mental disorders stimulated revolution in the efforts of development of a classification system in the United States. The National census of 1840 used a single category, “idiocy/insanity”. Seven categories of mental disorders were mentioned in the 1880 census: mania, melancholia, monomania, paresis, dementia, dipsomania, and epilepsy. The American Psychiatric Association (APA), then known as Committee on Statistics, together with the National Commission on Mental Hygiene, developed a new guide for mental hospitals called the “Statistical Manual for the Use of Institutions for the Insane” in 1917, which included 22 diagnoses. Subsequently, this was revised several times by APA over the years.
Foundations of Psychopathology criteria for each of the disorders mentioned. There was a multi-axial classification with five axes. DSM-III provided a vast increase in background information about each disorder, adding diagnostic features, associated features, cultural and gender features; prevalence, course, familiar patterns, differential diagnosis, decision trees and glossary. However, DSM-III was later criticized on the ground that 20- percent of the population would have been diagnosed as having behavioural disorders without having any serious mental problems. DSM-III-R (1987): The DSM-III-R was published as a revision of DSM-III in
- Categories were renamed, reorganised, and significant changes in criteria were made. Six categories were deleted, while some new categories were added. Controversial diagnoses such as pre-menstrual dysphoric disorder and Masochistic Personality Disorder were discarded. “Sexual orientation disturbance” was also removed and was largely subsumed under “sexual disorder not otherwise specified” which can include “persistent and marked distress about one’s sexual orientation.” DSM-III-R contained 292 diagnoses and was 567 pages long. DSM-IV (1994): DSM-IV was published in 1994 listing 297 disorders in 886 pages. Process of development of DSM-IV included extensive literature review of diagnoses, analyses to determine required change in criteria and multicenter field trials relating diagnoses to clinical practice. A major change from previous versions was the inclusion of a clinical significance criterion to almost half of all the categories, which required symptoms cause “clinically significant distress or impairment in social, occupational, or other important areas of functioning”. DSM-IV (TR) (2000): A “Text Revision” of the DSM-IV, known as the DSM-IV- TR, was published in 2000. The diagnostic categories and the vast majority of the specific criteria for diagnosis were unchanged. The text sections giving extra information on each diagnosis were updated, as were some of the diagnostic codes in order to maintain consistency with the ICD.
2.5 DSM-IV (TR): THE CURRENT VERSION OF
DSM
The Diagnostic and Statistical Manual of Mental Disorders (DSM) is the standard for classifying mental disorders that are used by mental health professionals in the United States. It is intended to be applicable in a wide variety of contexts and used by clinicians and researchers of many different orientations, for example; biological, psychodynamic, cognitive, behavioural, interpersonal, family/systems. The DSM IV (Text Revision) has been designed for use across settings such as inpatient, outpatient, partial hospitalisation, consultation-liaison, clinic, private practice and primary care. Professionals that use the DSM diagnosis are psychiatrists, psychologists, social workers, nurses, occupational and rehabilitation therapists, counsellors and other health and mental health professionals. The DSM is also a necessary tool for collecting and communicating accurate public health statistics. The DSM consists of three major components/features: the diagnostic classification, the diagnostic criteria sets and the descriptive text. i) The Diagnostic Classification: The DSM-IV (TR) is a categorical classification system. The categories are prototypes, and a patient with a close approximation to the prototype is said to have that disorder with qualifiers, for example mild, moderate or severe forms of a disorder. For nearly half the disorders, symptoms must be sufficient to cause clinically significant distress or impairment in social, occupational,
2 9 or other important areas of functioning, although DSM-IV-TR removed the distress criterion from tic disorders and several of the paraphilias. Making a DSM diagnosis consists of selecting those disorders from the classification that best reflects the signs and symptoms that are afflicting the individual being evaluated. Associated with each diagnostic label is a diagnostic code, which is used primarily by institutions and agencies for data collection. These diagnostic codes are derived from the coding system used by all health care professionals in the United States, known as the ICD- 9-CM. ii) The Diagnostic Criteria: Each disorder included in the DSM-IV (TR) includes a set of diagnostic criteria including symptoms that are present and for how long. These criteria called inclusion criteria as well as those symptoms that must not be present called exclusion criteria qualify an individual for a particular diagnosis. Many users of the DSM-IV (TR) find these diagnostic criteria useful because they provide a compact description of each disorder. Use of this diagnostic criterion has increased diagnostic reliability and the likelihood that different individuals will assign the same diagnosis. It is important to remember that these criteria are meant to be used as a guideline by an informed clinician. iii) Descriptive Text: The third component of the DSM-IV (TR) is the descriptive text that accompanies each disorder. The text of the DSM-IV (TR) systematically describes each disorder under the following headings: Diagnostic Features; Subtypes and/or Specifies; Recording Procedures; Associated Features and Disorders; Specific Culture, Age, and Gender Features; Prevalence; Course; Familial Pattern; and Differential Diagnosis.
2.5.1 Multi-Axial Classifications
The DSM-IV (TR) recommends clinicians to assess an individual’s mental state across five factors or axes. Together the five axes provide a broad range of information about the individual’s functioning, not just a diagnosis. The system contains the following axes.
- Axis I: Clinical Disorders and Other Conditions That May Be a Focus of Clinical Attention: This axis incorporates a wide range of clinical syndromes, including anxiety disorders, mood disorders, schizophrenia and other psychotic disorders, adjustment disorders, and disorders usually first diagnosed during infancy, childhood, or adolescence (except for mental retardation, which is coded on Axis II). Axis I also includes relationship problems, academic or occupational problems, and bereavement, conditions that may be the focus of diagnosis and treatment but that do not in themselves constitute definable psychological disorders. Also coded on Axis I are psychological factors that affect medical conditions, such as anxiety that exacerbates an asthmatic condition or depressive symptoms that delay recovery from surgery. The Axis I clinical disorder categories are as follows:
- Disorders Usually First Diagnosed in Infancy, Childhood, or Adolescence
- Delirium, Dementia, and Amnestic and Other Cognitive Disorders
- Mental Disorders Due to a General Medical Condition Not Elsewhere Classified
- Substance Related Disorders
- Schizophrenia and Other Psychotic Disorders
- Mood Disorders
- Anxiety Disorders Classification of Psychopathology: DSM IV TR
Table 1: Psychosocial and Environmental Problems Problem Categories Examples Problems with primary support group Death of family members; health problems of family members; marital disruption in the form of separation, divorce, or estrangement; sexual or physical abuse within the family; child neglect; birth of a sibling Problems related to the social environment Death or loss of a friend; social isolation or living alone; difficulties adjusting to a new culture (acculturation); discrimination; adjustment to transitions occurring during the life cycle, such as retirement Educational problems Illiteracy; academic difficulties; problems with teachers or classmates; inadequate or impoverished school environment Occupational problems Work-related problems including stressful workloads and problems with bosses or co-workers; changes in employment; job dissatisfaction; threat of loss of job; unemployment Housing problems Inadequate housing or homelessness; living in an unsafe neighbourhood; problems with neighbours or landlord Economic problems Financial hardships or extreme poverty; inadequate welfare support Problems with access to health care services Inadequate health care services or availability of health insurance; difficulties with transportation to health care facilities Problems related to interaction with the legal system/crime Arrest or imprisonment; becoming involved in a lawsuit or trial; being a victim of crime Other psychosocial problems Natural or human-made disasters; war or other hostilities; problems with caregivers outside the family, such as counsellors, social workers, and physicians; lack of availability of social service agencies Source: Adapted from the DSM-IV-TR (APA, 2000)
- Axis V: Global Assessment of Relational Functioning (GARF): The clinician rates the client’s current level of psychological, social, and occupational functioning using a 0-100 scale. The clinician may also indicate the highest level of functioning achieved for at least a few months during the preceding year. The level of current functioning indicates the current need for treatment or intensity of care. The level of highest functioning is suggestive of the level of functioning that might be restored. The GARF Scale can be used to indicate an overall judgment of the functioning of a family or other ongoing relationship on a hypothetical continuum ranging from competent, optimal relational functioning to a disrupted, dysfunctional relationship (APA, 2000). Classification of Psychopathology: DSM IV TR
Foundations of Psychopathology Table 2: Global Assessment of Functioning (GAF) Scale Source: Adapted from the DSM-IV-TR (APA, 2000) Code Severity of Symptoms Examples 91 - 100 Superior functioning across a wide variety of activities of daily life Lacks symptoms Handles life problems without them “getting out of hand” 81 - 90 Absent or minimal symptoms, no more than everyday problems or concerns Mild anxiety before exams Occasional argument with family members 71 - 80 Transient and predictable reactions to stressful events, or no more than slight impairment in functioning Difficulty concentrating after argument with family Temporarily falls behind in schoolwork 61 - 70 Some mild symptoms, or some difficulty in social, occupational, or school functioning, but functioning pretty well Feels down, mild insomnia Occasional truancy or theft within household 51 - 60 Moderate symptoms, or moderate difficulties in social, occupational, or school functioning Occasional panic attacks Few friends, conflicts with co- workers 41 - 50 Serious symptoms, or any serious impairment in social, occupational, or school functioning Suicidal thoughts, frequent shoplifting Unable to hold job, has no friends 31 - 40 Some impairment in reality testing or communication, or major impairment in several areas Speech illogical Depressed man or woman unable to work, neglects family, and avoids friends 21 - 30 Strong influence on behaviour of delusions or hallucinations, or serious impairment in communication or judgment, or inability to function in almost all areas Grossly inappropriate behaviour, speech sometimes incoherent Stays in bed all day, no job, home, or friends 11 - 20 Some danger of hurting self or others, or occasionally fails to maintain personal hygiene, or gross impairment in communication Suicidal gestures, frequently violent Smears feces 1 - 10 Persistent danger of severely hurting self or others, or persistent inability to maintain minimal personal hygiene, or seriously suicidal act Largely incoherent or mute Serious suicidal attempt, recurrent violence
Foundations of Psychopathology natural boundaries between related DSM syndromes or between a common DSM syndrome and normality have failed (Dalal & Sivakumar, 2009). Some argue that rather than a categorical approach, a fully dimensional, spectrum or complaint-oriented approach would better reflect the evidence (Bentall, 2006). In addition, it is argued that the current approach based on exceeding a threshold of symptoms does not adequately take into account the context in which a person is living and to what extent there is internal disorder of an individual versus a psychological response to adverse situations (Wakefield, Schmitz, First, & Horwitz, 2007).. Axis IV of the DSM-IV (TR) includes a step for outlining “Psychosocial and environmental factors contributing to the disorder” once someone is diagnosed with that particular disorder. Because an individual’s degree of impairment is often not correlated with symptom counts and can stem from various individual and social factors, the DSM’s standard of distress or disability can often produce false positives (Spitzer & Wakefield, 1999). On the other hand, individuals who don’t meet symptom counts may nevertheless experience comparable distress or disability in their life. iv) Cultural Bias: Some psychiatrists argue that diagnostic standards of DSM-IV (TR) rely on an exaggerated interpretation of neurophysiological findings and so understate the scientific importance of social-psychological variables (Widiger, & Sankis, 2000). It is contended that the cultural and ethnic diversity of individuals is often discounted by researchers and service providers. In addition, current diagnostic guidelines have been criticized as having a fundamentally Euro- American outlook. It is argued that even when diagnostic criteria set is accepted across different cultures, it does not necessarily indicate that the underlying constructs have any validity within those cultures and reliable application can only demonstrate consistency, not legitimacy (Widiger, & Sankis, 2000). v) Influence of Drug Companies: The way the categories of the DSM-IV (TR) are structured and the number of categories have been substantially expanded is often attributed to the influence of pharmaceutical companies and psychiatrists (Healy, 2006). Roughly half of the authors who selected and defined the DSM- IV psychiatric disorders had financial relationships with the pharmaceutical industry at one time, raising the prospect of a direct conflict of interest. In view of these criticisms and in pursuit of continuous improvements, the next (fifth) edition of the Diagnostic and Statistical Manual of Mental Disorders, DSM-5, is currently in consultation, planning and preparation. It is due for publication in May
- APA has made its draft versions public which includes several changes, including proposed deletion of several types of schizophrenia. Self Assessment Questions
1) Explain the process of development of various editions of DSM. ..................................................................................................................... ..................................................................................................................... ..................................................................................................................... ..................................................................................................................... 2) Describe the major components of DSM-IV (TR). .....................................................................................................................
- Present an account of multi-axial approach to the classification of psychopathology as provided by DSM-IV (TR). ..................................................................................................................... ..................................................................................................................... ..................................................................................................................... .....................................................................................................................
- Evaluate DSM-IV (TR) with its merits and demerits. ..................................................................................................................... ..................................................................................................................... ..................................................................................................................... .....................................................................................................................
2.7 LET US SUM UP
Classification of psychological disorders refers to the process to construct categories of abnormal behaviours and to assign people to these categories on the basis of their behavioural attributes and dysfunctional symptoms. It fulfils the basic purposes of communication, control, comprehension, distinction and prognosis/prediction of psychological disorders. Psychologists use three approaches or strategies to classify disorders: categorical, dimensional and prototypical approach. There have been a number of individual efforts of classification of mental disorders. This worldwide organised effort for classification of diseases was stimulated by the publication of International Statistical Classification of Diseases and Related Health Problems- (ICD-1) by the World Health Organisation in 1900. However, it was only ICD- which was published with a separate section on mental disorder in 1949. The most recent, tenth edition of ICD was published in 1992 in which chapter V (F) pertained to the classification of mental disorders explaining their inclusion and exclusion terms. The most influential efforts of classification of psychological disorders began with The Diagnostic and Statistical Manual of Mental Disorders (DSM), published by the American Psychiatric Association which is now used as the handbook for diagnosing mental disorders in the United States and other countries. After publication of its first edition, DSM-1 in 1952, its five subsequent editions have been published. The current version of DSM is DSM-IV (TR) published in 2000. The DSM-IV (TR) consists of three major components/features: the diagnostic classification, the diagnostic criteria sets and the descriptive text. The DSM-IV (TR) recommends clinicians to assess an individual’s mental state across five factors or axes. Together the five axes provide a broad range of information about the individual’s functioning, not just a diagnosis. Axis I assesses clinical disorders and other conditions that may be a focus of clinical attention. This axis incorporates a wide range of clinical syndromes, including anxiety disorders, mood disorders, schizophrenia and other psychotic disorders, adjustment disorders, and disorders usually first diagnosed during infancy, childhood, Classification of Psychopathology: DSM IV TR
Personality Disorders : Personality disorders are enduring and rigid patterns of maladaptive behaviour that typically impair relationships with others and social functioning. These include antisocial, paranoid, narcissistic, and borderline personality disorders. Mental Retardation : Mental retardation involves pervasive intellectual impairment. Global Assessment of : A 0-100 scale on which the clinician rates the Relational Functioning (GARF) client’s current level of psychological, social and occupational functioning using. Validity and reliability : This refers to whether the disorders as a of a Classification System classification system defines are actually real conditions in people in the real world that can be consistently identified by its criteria.
2.10 SUGGESTED READINGS
Barlow, D. H., & Durand, V. M. (2005). Abnormal psychology: An integrative approach (4th^ ed). Belmont, CA: Thomson-Wadsworth. Carson, R. C., Butcher, J. N., & Mineka, S. (2002). Clinical assessment and treatment. In Fundamentals of Abnormal Psychology and Modern Life. New York: Allyn & Bacon. References American Psychiatric Association. (2000). “Diagnostic and Statistical Manual of Mental Disorders” ( th ed.). APA: Washington, DC. Bentall, R. (2006). Madness explained: Why we must reject the Kraepelinian paradigm and replace it with a ‘complaint-orientated’ approach to understanding mental illness. Medical hypotheses, 66(2), 220-233. Dalal PK, & Sivakumar T. (2009). Moving towards ICD-11 and DSM-5: Concept and evolution of psychiatric classification. Indian Journal of Psychiatry, 51, 310-
DSM-IV-TR Official Site. http://psych.org/MainMenu/Research/DSMIV.aspx: American Psychiatric Association. Healy, D. (2006). The latest mania: Selling bipolar disorder. PLoS Med, 3(4), 185. International Statistical Classification of Diseases and Related Health Problems. Tenth Revision. Vol. 1: Tabular list. Vol. 2: Instruction manual. Vol. 3: Index. World Health Organisation: Geneva, 1992. McLaren, N. (2007). Humanizing Madness. Ann Arbor, MI: Loving Healing Press. Seligman, L. (1990). Selecting effective treatments: A comprehensive systematic guide to treating adult mental disorders. San Francisco: Jossey-Bass. Spitzer, R. L, & Wakefield, J. C. (1999). DSM-IV diagnostic criterion for clinical significance: does it help solve the false positives problem? American Journal of Psychiatry. 156(12), 1856-64. Classification of Psychopathology: DSM IV TR
Foundations of Psychopathology The ICD-10 Classification of Mental and Behavioural Disorders. Clinical descriptions and diagnostic guidelines. World Health Organisation: Geneva, 1992. Wakefield, Jerome C., Schmitz, Mark F., First, Michael B., & Horwitz, Allan V. (2007). Extending the Bereavement Exclusion for Major Depression to Other Losses: Evidence from the National Comorbidity Survey. Arch Gen Psychiatry, 64, 433-
Widiger, T. A. & Sankis, L. M. (2000). Adult psychopathology: issues and controversies. Annual Review of Psychology, 51, 377–404.
