CHAPTER 7: DIAGNOSIS AND CLASSIFICATION ISSUES health professionals every day as they perform assessments, conduct

therapy, and design and execute research studies.

DEFINING NORMALITY AND ABNORMALITY
- Its authors offer a broad definition of mental disorder.
• Abnormality, also known as mental disorders, psychiatric diagnoses, or, - It is not entirely dissimilar to Wakefield’s harmful dysfunction theory,
more broadly, psycho pathology. yet it also incorporates aspects of the other criteria.
• Through their training and their professional activities, clinical • In DSM-5, mental disorder is defined as a “clinically significant
psychologists become very familiar with the definitions of various forms disturbance” in “cognition, emotion regulation, or behavior” that
of abnormal behavior and the ways it differs from normal behavior. indicates a “dysfunction” in “mental functioning” that is “usually
associated with significant distress or disability” in work, relationships,
What Defines Abnormality? or other areas of functioning.
➢ Who created this definition, as well as the specific diagnostic categories
• These answers have included criteria such as personal distress to the
that fill DSM?
individual (as in severe depression or panic disorder)
- the most significant were those on the Task Force for each edition
• Deviance from cultural norms (as in many cases of schizophrenia)
of the DSM.
• Statistical infrequency (as in rarer disorders such as dissociative
- This group consisted largely of leading researchers in various
identity disorder)
specialty areas within psycho pathology who were selected for their
• Impaired social functioning (as in social phobia and, in a more
scholarship and expertise in their respective fields.
dangerous way, antisocial personality disorder).
- Consisted primarily of psychiatrists, and a relatively small number
• In the 1990s, Jerome Wakefield, a renowned scholar in the field of
of psychologists and other mental health professionals were
abnormal psychology, offered a theory that put forth a more simplified
included.
definition of mental disorders.
• The DSM-5 and all previous editions of the DSM have been published by
- Wakefield (1992) explains his harmful dysfunction theory of
the American Psychiatric Association (as opposed to the American
mental disorders in the following way:
Psychological Association). Thus, although the DSM has been used
o I argue that a disorder is a harmful dysfunction, wherein harmful is a
extensively by clinical psychologists and a wide range of other
value term based on social norms, and dysfunction is a scientific term
nonmedical mental health professionals, the authors who have had the
referring to the failure of a mental mechanism to perform a natural
most significant impact on its contents are medical doctors.
function for which it was designed by evolution. Thus, the concept of
• DSM reflects a medical model of psychopathology in which each
disorder combines value and scientific components.
disorder is an entity defined categorically and features a list of specific
• The harmful dysfunction theory proposes that in our efforts to
symptoms.
determine what is abnormal, we consider both scientific data and the
➢ Besides their profession, what else do we know about the primary
social values in the context of which the behavior takes place.
authors of the DSM?
Who Defines Abnormality? - The first edition of the DSM, published in 1952, was created by the
foremost mental health experts of the time, who were almost
• Wakefield’s definition of abnormality, along with other definitions, exclusively white, male, trained in psychiatry, at least middle age,
continues to be debated by academics and researchers in the field. and at least middle class.
• They use disorders as defined by the Diagnostic and Statistical Manual - In spite of this forward progress, some have remained critical: “The
of Mental Disorders (DSM), the prevailing diagnostic guide for mental designers of the DSM-III and DSM-III-R were still predominantly
 senior White male psychiatrists who embedded the document with Importance for Professionals
their biases”
• If attenuated psychosis syndrome becomes an official diagnosis, we will
Considering Culture undoubtedly see an increase in both of these activities.
• If attenuated psychosis syndrome becomes official, people will be
Typical but Abnormal?
diagnosed with it and will be conceptualized as having this form of
• At one time or another, many of us have used the “everybody else is mental illness.
doing it” explanation to rationalize our aberrant behavior. • If attenuated psychosis syndrome had never appeared in any form in any
• Drivers who speed, kids who steal candy, partiers who drink too much, edition of DSM, it is less likely that researchers would study it or
citizens who cheat on their taxes: Any of them might argue, “I’m not the clinicians would add it to their professional vocabulary.
only one,” and they’d be right. • And the same people who would have received the diagnosis would be
➢ Should the commonality of a behavior affect the way we evaluate that viewed as slightly odd or eccentric but not mentally ill.
behavior?
Importance for Clients
- Thomas A. Widiger and Stephanie Mull ins-Sweatt (2008)
considered the issue and came to this conclusion: “Simply because ✓ Consider Lucinda, a woman whose experience over the past few months
a behavior pattern is valued, accepted, encouraged, or even meets the criteria for attenuated psychosis syndrome.
statistically normative within a particular culture does not - If this disorder was available as an official label, the label could help
necessarily mean it is conducive to healthy psychological Lucinda identify and demystify an otherwise nameless experience;
functioning”. feel as though she shares a recognized problem with others
acknowledge the significance of her experience with family, friends,
Why Is the Definition of Abnormality Important?
and employers; and gain access to treatment that might have been
• Attenuated psychosis syndrome is not an official diagnostic category. unavailable without a diagnosis.
- It is listed as a proposed criteria set in the “Emerging Measures and - Lucinda could also experience harmful consequences from being
Models” section of DSM-5. diagnosed with attenuated psychosis syndrome.
- This section describes conditions that DSM authors decided to - The label could carry a stigma that damages her self-image; lead to
leave out of the list of “official” disorders, at least for now, but to list stereotyping by individuals who know her or work with her; and even
as “unofficial” conditions for the purpose of inspiring clinicians and have an effect on the outcome of legal issues she may encounter,
researchers to study them more. such as child custody cases, sentencing decisions, and fitness to-
- Attenuated psychosis syndrome is a bit like a “light” version of stand-trial decisions.
schizophrenia (“attenuated” means reduced or lessened). - The decisions DSM authors make when defining abnormality, both
- Its symptoms include delusions, hallucinations, and disorganized as a broad concept and as specific diagnostic categories,
speech that are not severe or long-lasting. profoundly influence many aspects of clients’ lives.
- The person’s “reality testing” her or his ability to stay in touch with
In My Practice . . .
the same reality that the rest of us experience remains relatively
intact. ✓ In one case, Teresa, a 35-year-old woman, sought therapy after
- The symptoms must be present only once per week within the last considering it for a long time.
month but must be distressing or disabling. - She explained, was the fact that her 11-year-old son, Thomas, had
recently been diagnosed with major depression by his pediatrician.
 Teresa held the mistaken belief that DSM diagnoses were - He pointed to an imbalance of bodily fluids (blood, phlegm, black
permanent. bile, and yellow bile) as the underlying reason for various forms of
- A primary goal for my work with Teresa was to help her understand mental illness.
that many DSM diagnoses, including major depression, were • Hippocrates to the 19th century, we find an era when many cities in
unlikely to be permanent conditions, especially with treatment. Europe and the United States were establishing asylums for the
✓ Julian, a 30-year-old man. Julian was overly concerned with germs and treatment of the mentally ill.
cleanliness. - In these inpatient treatment settings, mental health professionals
- These behaviors didn’t prevent him from living his life he had a long- had the opportunity to observe individuals with mental disorders for
term romantic relationship, performed well at work, and had an extended periods of time.
active social life but there were at least occasional moments when ✓ One example occurred in France, where Philippe Pinel proposed
his need to wash got in the way. specific categories such as melancholia, mania, and dementia, among
- I told Julian that I believed his problems were best diagnosed as a others.
mild case of obsessive-compulsive disorder. - The staff of some of these institutions shared their idiosyncratic
- As soon as the words “obsessive-compulsive disorder” left my diagnostic systems with one another, and more common
mouth, Julian’s face went blank. He explained that he “knows what terminology evolved.
happens” to people with OCD: “They keep getting worse and worse • Around 1900, more important steps were taken toward the eventual DSM
until their symptoms totally take over. Pretty soon, I’m gonna be a system that we currently use.
prisoner in my own house. I won’t be able to go out, work, or do - Emil Kraepelin labeled specific categories such as manic-
anything. I’ll turn into a total germophobe who washes himself all depressive psychosis and dementia praecox (roughly equivalent to
day every day.” bipolar disorder and schizophrenia).
- I told him emphatically that OCD does not inevitably get worse. I - Resulted in his reputation as a founding father of the current
added that as his psychologist, I had a lot of confidence that with diagnostic system.
treatment his OCD symptoms would actually improve significantly. • During the late 1800s and early 1900s, the primary purpose of
It took Julian a while to believe me, but once he did, his treatment diagnostic categories was the collection of statistical and census data.
was on track. • Later, in the mid-1900s, the U.S. Army and Veterans Administration (now
Veterans Affairs) developed their own early categorization system in an
DIAGNOSIS AND CLASSIFICATION OF MENTAL DISORDERS: A BRIEF
effort to facilitate the diagnosis and treatment of soldiers returning from
HISTORY
World War II.
Before the DSM
DSM—Earlier Editions (I and II)
• Abnormal behavior garnered attention long, long before the first version
• DSM-I was published by the American Psychiatric Association in 1952.
of the DSM appeared.
• DSM-II followed as a revision in 1968.
• Discussion of abnormal behavior appears in the writings of ancient
Chinese, Hebrew, Egyptian, Greek, and Roman societies. • These two editions of the DSM were quite similar to each other, but as a
pair, they were quite different from all the DSM editions subsequently
• Hippocrates (460–377 BCE) wrote extensively about abnormality, but
published.
unlike most of his predecessors, he did not offer supernatural
explanations such as possession by demons or gods. • DSM-I and DSM-II contained only three broad categories of disorders:
- Instead, his theories of abnormality emphasized natural causes. o Psychoses which would contain today’s schizophrenia.
 o Neuroses which would contain today’s major depression, ▪ Axes III and IV offered clinicians a place to list medical conditions
bipolar disorder, and anxiety disorders. and psychosocial/environmental problems, respectively, relevant to
o Character disorders which would contain today’s personality the mental health issues at hand.
disorders. ▪ Axis V, known as the Global Assessment of Functioning (GAF)
- They represented “the accumulated clinical wisdom of the small scale, provided clinicians an opportunity to place the client on a
number of senior academic psychiatrists who staffed the DSM task 100-point continuum describing the overall level of functioning.
forces” • DSM-III offered extended descriptions and added lists of specific
- Most of these psychiatrists were psychoanalytic in orientation, and criteria.
the language of the first two DSM editions reflected the - it included many new disorders 265 disorders in total.
psychoanalytic approach to understanding people and their • 182 in DSM-II
problems. • 106 in DSM-I
- The descriptions of individual disorders in DSM-I and DSM-II were • DSM-III-R, DSM-IV, DSM-IV-TR retained the major quantitative and
not lists of specific symptoms or criteria; instead, they were simply qualitative changes instituted by DSM-III in 1980.
prose, typically one paragraph per disorder, offering relatively vague • DSM-5 retained many of these changes as well, although it also features
descriptions of clinical conditions. some significant changes of its own.
- They had very limited generalizability or utility for clinicians in • Several features of the DSM-II definition are noteworthy, including the
practice at the time. psychoanalytically derived term neurosis in the title of the disorder and
DSM—More Recent Editions (III, III-R, IV, and IV-TR) the use of a brief descriptive paragraph rather than the more detailed
checklist of specific criteria.
• DSM-III, published in 1980, was very dissimilar from DSM-I and DSM-II.
DSM-5: The Current Edition
• In comparison to DSM-I and DSM-II, it reflected an approach to defining
mental disorders that differed substantially in some important ways: • In May 2013, DSM-5 was published.
o It relied to a much greater extent on empirical data to • First substantial revision of the manual in about 20 years.
determine which disorders to include and how to define them. • Led by two prominent mental health researchers: David Kupfer and
o It used specific diagnostic criteria to define disorders. Darrel Regier, it involved hundreds of experts from over a dozen
Whereas the DSM-III retained some descriptive paragraphs countries contributing their time and expertise over a 12-year period that
these paragraphs were followed by specific criteria checklists, was particularly intensive in the last half-dozen years before its release
that delineated in much greater detail the symptoms that must
• Work Groups reviewed the disorders listed in the previous DSM and
be present for an individual to qualify for a diagnosis.
considered proposals for revision, including ideas for adding,
o It dropped any allegiance to a particular theory of therapy or
eliminating, combining, splitting, or revising the definitions of disorders.
psychopathology. As a result, the psychoanalytic language of
• The leaders also created a Scientific Review Committee of experts
previous editions was replaced by terminology that reflected no
separate from the Work Groups whose job was to make sure that there
single school of thought.
was sufficient scientific evidence to support the changes proposed by
o It introduced the multiaxial assessment system that remained
the Work Groups.
in DSM through the next several editions but was dropped in
- Later in the process, they asked practicing clinicians to try using
DSM-5.
them with clients, with the intention of determining how reliable and
▪ Axis I included disorders thought to be more episodic.
clinically useful they were.
▪ Axis II included disorders thought to be more stable or long-lasting.
 • Beginning in 2010, the DSM-5 authors maintained a website ([Link]) - A significant body of research has accumulated to suggest that
on which they communicated to the public about their progress, personality disorders fit best with the idea of dimensional, as
including posts of the drafts of proposed changes. opposed to strictly categorical, conceptualization.
- And they received plenty over 13,000 comments through the - The DSM-5 authors proposed a specific way of understanding
website, plus another 12,000 in other forms such as e-mail and personality disorders dimensionally, but the proposal was rejected
letters as being too complex and not clinically useful enough.
• Throughout the process, the DSM-5 authors tried to coordinate their - The proposal is included in a later section of DSM-5 called
efforts with those of the World Health Organization (WHO), which “Emerging Measures and Models” with the hope that researchers
publishes the International Classification of Diseases (ICD). will study and possibly revise it for future consideration.
• ICD is the primary way that diseases both mental dis orders and all other • The DSM-5 authors considered removing 5 of the 10 personality
health-related problems are coded and categorized in many countries disorders previously included in that section, a change that would have
outside the United States. significantly reshaped that category.
- The five that were on the chopping block at one point were paranoid,
Changes DSM-5 Did Not Make schizoid, histrionic, dependent, and narcissistic personality
Changes they considered but ultimately did not make: disorders.
• There were numerous proposals for specific new disorders that were
• The authors of DSM-5 considered significantly overhauling the manual considered but rejected. Many of these appear in the “Emerging
to emphasize neuropsychology, or the biological roots, of mental Measures and Models” section as “proposed criteria set”:
disorders. This would have been a significant paradigm shift in which the 1. Attenuated psychosis syndrome, which features the
fundamental way we define mental disorders changes from descriptions hallucinations, delusions, and disorganized speech characteristic
of behavioral symptoms to biological evidence. of schizophrenia but in much less intense and more fleeting forms,
- Although there are many mental disorders that involve biological and in which the person doesn’t lose touch with reality in a pervasive
factors, those disorders lack definitive, reliable “biological markers” way.
the kinds of things that indicate that a person “tests positive” or 2. Mixed anxiety-depressive disorder, which features some
“tests negative” in a conclusive way. symptoms of anxiety, some symptoms of depression, but not
- Such biological markers may become known in time as enough of either to qualify for any existing disorder.
neuroscience advances, but for now, research has simply not yet 3. Internet gaming disorder, which features excessive and disruptive
uncovered them clearly enough to use them as diagnostic tools. Internet game-playing behavior.
• The shift toward a dimensional definition of mental disorders.
- It involves viewing disorders not strictly in a categorical or “yes or no” New Features in DSM-5
way, but along a continuum. Some of the most significant changes in DSM-5 do not focus on specific
- Rather than describing a client only as either “having” or “not disorders but on the way the entire manual is organized or presented:
having” major depressive disorder, the clinician could rate the
client’s depression symptoms on a scale. • The title of the manual is not DSM-V, but DSM-5.
• A dimensional approach was also seriously considered for a particular - The authors deliberately shifted away from the traditional Roman
subset of mental disorders: personality disorders. numerals used in previous editions and toward Arabic numerals
instead.
 - The reason for this shift is to enable more frequent minor updates - Frequent temper tantrums in children 6 to 18 years old (at least three
that will be named just as changes to computer operating systems tantrums per week over the course of a year)
and applications are often named: DSM-5.1, DSM-5.2, et cetera. - The creation of this new diagnosis was prompted by the drastic
- DSM is a “living document” that, in the future, will be more quick to increase in the diagnosis of bipolar disorder in children in recent
respond to new research that improves our understanding of mental decades.
disorders. 3. Binge eating disorder (BED)
- The “Emerging Measures and Models” section of the manual goes - Part of bulimia nervosa in which the person overindulges in food but
hand in hand with this notion of a living document, as it prompts lacks the part in which the person tries to subtract the calories
researchers and clinicians to consider conditions that have not yet through compensatory behaviors like excessive exercise.
been officially included in DSM but may, after more attention, be - Binges must take place at least once per week for 3 months and be
included in future editions. accompanied by a lack of control over the eating as well as other
• The multiaxial assessment system—a central feature of DSM since its symptoms like rapid eating, eating until overly full, eating alone to
introduction in DSM-III in 1980 was dropped altogether from DSM-5. avoid embarrassment, and feelings of guilt or depression afterward.
- This removal brings a number of important changes to the way 4. Mild neurocognitive disorder (mild NCD)
clinicians diagnose clients. - A less intense version of major neurocognitive problems like
✓ For example, the tradition of separate axes for disorders that tend to dementia and amnesia.
persist long-term (such as developmental disorders and personality - It requires modest decline in such cognitive functions as memory,
disorders, formerly on Axis II) from disorders that tend to be more short- language use, attention, or executive function, but nothing serious
term or episodic (such as major depression, formerly on Axis I) is now enough that it interferes with the ability to live independently.
gone. 5. Somatic symptom disorder (SSD)
- Axis V, the Global Assessment of Functioning (GAF) scale, is now - A combination of at least one significantly disruptive bodily
eliminated, so there is no longer a single numeric scale on which (somatic) symptom with excessive focus on that symptom that
clinicians can describe their clients’ level of functioning across all involves perceiving it as more serious than it really is, experiencing
disorders. high anxiety about it, or devoting excessive time and energy to it.
6. Hoarding disorder
New Disorders in DSM-5
- Continuing difficulty discarding possessions no matter how
DSM-5 introduced a number of new disorders not merely revisions or regroupings objectively worthless they are and, as a result, lives in a congested
of existing disorders but disorders that, at least to some extent, cover problems or cluttered home and experiences impairment in important areas
that were not covered by any disorders in the previous edition of the manual: such as work, socialization, or safety.

1. Premenstrual dysphoric disorder (PMDD) Revised Disorders in DSM-5

- A severe version of premenstrual syndrome (PMS).
Changes in DSM-5 involved established disorders being revised in some way
- A combination of at least five emotional and physical symptoms
diagnostic criteria were modified, disorders were combined, or age limits were
occurring in most menstrual cycles during the last year that cause
adjusted.
clinically significant distress or interfere with work, school, social
life, or relationships with others. • The “bereavement exclusion” formerly included in the diagnostic
2. Disruptive mood dysregulation disorder (DMDD) criteria for major depressive episode was dropped.
 - Major depression could not be diagnosed in a person who was • The category of Mood Disorders was split into two: Depressive
mourning (or bereaving) the death of a loved one during the first two Disorders (in which mood is singularly sad) and Bipolar and Related
months following the death. The rationale for the exclusion was that Disorders in which mood alter nates between sadness and mania.
the sadness that commonly comes with such loss should not be
Controversy Surrounding DSM-5
confused with the mental disorder of major depression.
• The DSM-IV diagnoses of autistic disorder, Asperger’s disorder, and • DSM-5 arrived in May 2013 amid controversy that had already been
related developmental disorders were combined into a single DSM-5 swirling for many months.
diagnosis: autism spectrum disorder. • Coverage of controversy extended well past the United States into
- According to DSM-5 authors, they represent various points on the Europe, Australia, Asia, and South America.
same spectrum of impairment, defined by social communication • Members of multiple DSM-5 Work Groups quit in the middle of the
problems and restrictive or repetitive behaviors and interests. revision, publicly casting doubt on the process used to create the DSM-
• In the criteria for attention-deficit/hyperactivity disorder (ADHD), the 5.
age at which symptoms must first appear was changed from 7 to 12 • Letters of protest came from leaders of multiple mental health
years old, and the number of symptoms required for the diagnosis to organizations, including Division 32 (Society of Humanistic Psychology)
apply to adults was specified as five. of the American Psychological Association, the American Counseling
• In the criteria for bulimia nervosa, the frequency of binge eating Association, and the British Psychological Society.
required for the disorder was dropped from twice per week to once per • Numerous mental health professionals called for a boycott of DSM-5.
week. • The majority of the commentary surrounding DSM-5 was critical, and the
- The requirement that menstrual periods stop has been omitted, and most vocal critic was Allen Frances who was the chair of the Task Force
the definition of low body weight has been changed from a numeric for DSM-IV.
definition (less than 85% of expected body weight) to a less specific - He led the previous revision of the manual that was published in
description that takes into account age, sex, development, and 1994.
physical health. - He had direct experience with the enormous challenge and
• The two separate DSM-IV diagnoses of substance abuse and substance consequences of producing a new DSM.
dependence have been combined into a single diagnosis: substance - Had actually been retired for almost a decade, with no intention of
use disorder. being involved in DSM-5 at all, until he found himself at a cocktail
- Tolerance and withdrawal, which had been solely linked to party at the annual meeting of the American Psychiatric Association
substance dependence in DSM-IV were not in fact solely in 2009 and was pulled into the debate about DSM-5 by colleagues
experienced by those with substance dependence but also by who informed him about the revision process.
people who use substances in various capacities. - Frances has put forth a steady stream of articles, blog posts, radio
• Mental retardation was renamed intellectual disability (intellectual and TV appearances, and even a full book on the flaws and failings
development disorder), and learning disabilities in reading, math, and of DSM-5.
writing were combined into a single diagnosis with a new name: specific ▪ “This is the saddest moment in my 45-year career of studying, practicing,
learning disorder and teaching psychiatry….”
• Obsessive-compulsive disorder was removed from the anxiety disorders ▪ “With the DSM-5, patients worried about having a medical illness will
category and placed into its own new category, Obsessive-Compulsive often be diagnosed with somatic symptom disorder…”
and Related Disorders, which also includes trichotillomania (hair-
pulling), excoriation (skin-picking), and body dysmorphic disorder.
▪ “[I have offered many] warnings about the risks that DSM-5 will mislabel 5. Price.
normal people, promote diagnostic inflation, and encourage - The original list price for DSM-5 was $199 hardback, $149
inappropriate medication use…” paperback, and $149 e-book.
▪ “My advice is to ignore DSM-5. t is not well done. It is not safe. Don’t buy - When DSM-IV was released in 1994, it cost $65
it. Don’t use it. Don’t teach it.”
➢ Many others offered harsh criticism of many aspects of DSM-5, What,
specifically, did they criticize?
1. Diagnostic overexpansion.
- Its diagnoses cover too much of normal life. Criticisms of the DSM
- Too often it takes difficult or inopportune life experiences and • The most recent editions of DSM have been widely used by all mental
labels them as mental illnesses health professions, and they undeniably represent improvements over
2. Transparency of the revision process. their predecessors in some important ways.
- Some critics argued that they were vague and selective about • Strengths of recent editions include their emphasis on empirical
what they shared, that too many of their ideas and decisions research, the use of explicit diagnostic criteria, interclinician
were eventually made behind closed doors, and that the reliability, and atheoretical language.
members of the Work Groups were required to sign
• The DSM has facilitated communication between researchers and
confidentiality agreements to keep their processes out of public
clinicians by providing a common professional language that has
awareness
become very widely accepted
3. Membership of the work groups.
- Those who were invited into the DSM-5 revision process were, Considering Culture
predominantly, researchers.
Are Eating Disorders Culturally Specific?
- They understand the disorders in their area of expertise in terms
of designing and conducting empirical studies, but some of • DSM-5 includes a Glossary of Cultural Concepts of Distress, which lists
them do not practice at all, and those who do may only do so syndromes and experiences that are relatively unique to particular
minimally, so their ability to assess the impact of DSM changes cultures.
on full-time clinicians practicing in real world clinics, hospitals, • Anorexia and bulimia are included among the official DSM disorders
and private practices may have been lacking. rather than among the cultural concepts of distress.
- DSM-5 also received criticism from the director of the National • Pamela K. Keel and Kelly L. Klump (2003) conducted an extensive study
Institute of Mental Health (NIMH), a leading funding agency for of this question, examining the incidence rates of anorexia and bulimia
mental health research, in which he announced that NIMH will in Western and non-Western parts of the world, as well as the history of
be developing its own Research Domain Criteria (RDoC) by these two dis orders before they were officially defined and labeled.
which to define mental health problems for research purposes. • These eating disorders were limited to West ern culture and were
4. Field trial problems. therefore culture-bound.
- The authors of DSM-5 ran field trials in which they tested the • Other researchers emphasized that factors besides culture, including
reliability of their new diagnoses with clinicians in real-world genetics, were the primary causes of these disorders.
clinical settings.
• They concluded that although anorexia did not meet their definition of a
- The problem, according to critics, is that some of the reliability
culture-bound condition, bulimia did.
ratings that these field tests produced were too low.
Breadth of Coverage Cultural Issues

• Some have argued that this expansion has been too rapid and that the • When DSM-IV arrived in 1994, it signaled important advances in the
result is a list of mental disorders including some experiences that consideration of cultural issues regarding mental disorders.
should not be categorized as forms of mental illness. • DSM-5 continues many of those advances.
• Houts (2002) points out that many of the newer disorders are not entirely - DSM-5 includes an “Outline for Cultural Formulation” and the
“mental” disorders, including some disorders with physical factors such accompanying “Cultural Formulation Interview” designed to help
as the sexual disorders, substance-related disorders, and sleep clinicians assess in a culturally competent way.
disorders. - It also includes a glossary of cultural concepts of distress, or terms
• Kutchins and Kirk (1997) and Caplan (1995) make the case that the used by various cultural groups to describe specific psychological
DSM includes an increasing number of disorders that are better conditions.
understood as problems in day-to-day life than as diagnosable mental • Despite this considerable progress toward improving cultural sensitivity,
illnesses. the recent editions of DSM have received pointed criticism for
shortcomings related to culture and diversity
Controversial Cutoffs
• Some detractors of the DSM have stated that very few of the empirical
• One of the essential differences between earlier and later editions of studies considered by the authors of the current DSM have focused
DSM is the presence of lists of specific symptoms and, moreover, sufficiently on ethnic minorities, which suggests that the DSM still may
specific cutoffs regarding those lists of symptoms. not reflect minority experiences.
✓ For example, the current diagnostic criteria for major depressive
Gender Bias
disorder include nine specific symptoms, at least five of which must be
present for at least a 2-week period. • Some disorders are diagnosed far more often in males: alcohol use
- Some have argued that these cutoffs have been arbitrarily or disorder, conduct disorder, ADHD, and antisocial personality disorder.
subjectively chosen by DSM authors and that, historically, the • Other disorders are diagnosed far more often in females: major
consensus of the DSM authors has played a significant role in these depression, many anxiety disorders, eating disorders, borderline
cutoff decisions. personality disorder, histrionic personality disorder.
- One reason why the cutoff for any disorder is especially relevant is • Critics of the current DSM have argued that some diagnostic categories
that third-party payers typically pay for treatment only if it is for a are biased toward pathologizing one gender more than the other.
diagnosed disorder. • Some empirical studies have found that clinicians define mental health
• “upcoding” can become an ethical issue for psychologists who want to differently for males and females and that clients of different genders
ensure that their clients receive their health insurance benefits even if with identical symptoms often receive different diagnoses from
they do not technically qualify for a DSM category. clinicians.
- Is falsely reporting that a client has a DSM diagnosis when in fact • The controversy over premenstrual dysphoric disorder (PMDD), which
they fall short of the criteria. had been rejected from previous editions of DSM but is now included as
✓ For example, if a client is somewhat anxious but the client’s symptoms a disorder in DSM-5, has renewed this criticism of DSM authors.
are not sufficient in quantity, severity, or duration to qualify for
generalized anxiety disorder, a psychologist may consider diagnosing Premenstrual Dysphoric Disorder
the client with the disorder anyway. Upcoding, of course, can constitute
• One of the most notable new disorders listed in DSM-5 is premenstrual
insurance fraud and a violation of professional ethics.
dysphoric disorder (PMDD).
 • It falls within the Depressive Disorders category, along with major • In addition to politics and public opinion, financial concerns may have
depressive disorder and other disorders that center around sad or played a role in some DSM decisions.
irritable mood. • As increasing numbers of therapy clients paid via health insurance in the
• It should not be equated with premenstrual syndrome (PMS), which is last several decades of the 20th century, clinicians found that, typically,
more common and less severe than PMDD. Instead, PMDD requires the health insurance companies required a diagnosis for payment.
either “clinically significant distress” or “interference with work, school,
Limitations on Objectivity
usual social activities, or relationships with others”.
• The diagnosis of PMDD requires at least five symptoms from a list of 11 • The leading authors of the DSM-IV and DSM-IV-TR stated that “although
occur ring in most menstrual cycles of the past year during the week based on empirical data, DSM-IV decisions were the results of expert
before the menstrual period, at least one of which is mood-related and consensus on how best to interpret the data”
at least one of which is behavioral or physical. • “Throughout the manufacture of the DSM, people are making decisions
• The idea of a PMDD diagnosis has generated controversy since it was and judgments in a social context. Whether or not a new set of behaviors
first proposed in the 1980s under the name “Late Luteal Phase warrants a diagnostic label depends on culturally varying judgments
Dysphoric Disorder” about what is clinically significant”
• It was considered for inclusion in previous editions of DSM and listed in
ALTERNATIVE DIRECTIONS IN DIAGNOSIS AND CLASSIFICATION
an appendix of conditions to be considered for the future in DSM-IV in
1994, but it became a full-fledged disorder in 2013 with the publication • DSM has always offered a categorical approach to diagnosis.
of DSM-5. - The word categorical refers to the basic view that an individual
• They have emphasized that it represents a form of gender bias likely to “has” or “does not have” the disorder
over pathologize women, especially since there is no parallel diagnosis - Individual can be placed definitively in the “yes” or “no” category
for men despite the fact that men also experience some degree of regarding a particular form of psychopathology.
hormonal fluctuations. • Dimensional approach has been proposed by a number of researchers
• They are better understood as physical or gynecological problems rather and clinicians.
than a form of mental illness, especially because they last a short time - The issue isn’t the presence or absence of a disorder; instead, the
and subside on their own without treatment. issue is where on a continuum (or “dimension”) a client’s symptoms
fall.
Nonempirical Influences
✓ As an example, consider Robert, a client with a strong tendency to avoid
Authors of recent editions of the DSM have increasingly used empirical evidence social situations because he fears criticism and rejection from others.
to determine the diagnostic categories, and the manual is certainly more reliable - A categorical system would require Robert’s psychologist to
as a result. determine whether Robert has a particular disorder perhaps social
phobia or avoidant personality disorder.
• Nonempirical influences have intruded on the process to some extent,
- A dimensional system wouldn’t require a yes or no answer to the
according to various commentators on the DSM process.
question. In place of this dichotomous decision, Robert’s
✓ For example, once-proposed disorders such as masochistic
psychologist would be asked to rate Robert on a continuum of
personality disorder have been strongly and publicly opposed by
anxious avoidance of social situations.
political organizations, and decisions not to include them officially in the
• The dimensions of psychological disorders may not be defined by
DSM may stem in part from this opposition.
traditional DSM categories. Instead, proponents of the dimensional
 approach to abnormality suggest that all of us the normal and the • Big Five: neuroticism, extraversion, openness, conscientiousness,
abnormal share the same fundamental characteristics but that we differ and agreeableness as characteristics that are common to all of us,
in the amounts of these characteristics that we each possess. including normal and abnormal individuals.
• What makes some of us abnormal is an unusually high or low level of • According to the dimensional model, what is abnormal about abnormal
one or more of these characteristics. people is the amount of one of these basic ingredients, extremely high
• The five-factor model of personality (also known as the “Big Five” neuroticism, extremely low extraversion, or extremely high openness, for
model) is a leading candidate, at least for the personality disorders, and example.
perhaps more broadly - Abnormal people have the same “ingredients” as normal people but
• According to the dimensional approach to abnormality, each of our in significantly different amounts, a quantitative difference
personalities contains the same five basic factors— neuroticism, • The categorical approach to psychopathology tends to believe that the
extraversion, openness to experience, agreeableness, and difference between abnormal and normal people is more qualitative,
conscientiousness. suggesting that abnormal people have an “ingredient” that normal
- These five factors could constitute the dimensions on which clinical people simply don’t have.
psychologists describe clients with personality problems. • A growing body of research suggests that the personality disorders can
- In the case of Robert instead of giving him a high rating on a be conceptualized quite well using the dimensional approach based on
dimension called “avoidant personality disorder” or “social phobia,” the Big Five personality factors.
the clinician might give the client a low rating on the dimension of • Empirical support for this theory has suggested several specific links:
extraversion. o Paranoid personality disorder is characterized by very low
• Categorical thinking is unavoidable and essential to our understanding agreeableness.
and communication about mental disorders. o Histrionic personality disorder is characterized by very high
extraversion.
Metaphorically Speaking
o Obsessive-compulsive personality disorder is characterized
If You’ve Eaten Chocolate Chip Cookies, You Understand the Dimensional Model by very high conscientiousness.
of Psychopathology o Borderline personality disorder is characterized by very high
neuroticism.
• If you bite into a chocolate chip cookie and it tastes unusual, atypical, or
even “abnormal,” what’s the reason?
- Perhaps it contains the same ingredients as other chocolate chip
cookies but simply in different amounts more sugar, less butter,
fewer chocolate chips than “normal” cookies, the difference
between “abnormal” and “normal” cookies could be quantitative.
- The “abnormal” cookie contains some entirely different ingredients
that “normal” cookies simply don’t contain nut meg, cinnamon,
pepper, garlic, or something else. In this case, the difference is
qualitative.
• They believe that all our personalities are made of the same short list of
“ingredients,” or traits.