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44 Chapter 2 Classification and Treatment Plans
person who has unusually low sexual desire would have a
diagnosable condition within the DSM-IV-TR called “hypoactive [low] sexual desire disorder.” Does it make sense to
refer to such a condition as a mental disorder?
Severe depression can be so devastating that some people consider
suicide their only option.
rituals and behaviors that might seem bizarre to outsiders
but are acceptable within the culture.
Assumptions of the DSM-IV-TR
Throughout the history of the DSM system, its authors have
debated a number of complex issues, including the theoretical basis of the classification system. Each edition of the
manual has represented thousands of hours of discussion
among experts in several related fields from different theoretical backgrounds. The DSM-IV today contains the result
of these discussions, and underlying its structure and organization are several important assumptions.
Medical Model One of the most prominent assumptions of
the DSM-IV-TR is that this classification system is based on
a medical model orientation, in which disorders, whether
physical or psychological, are viewed as diseases. In fact, as
we mentioned earlier, the DSM-IV-TR corresponds to the
International Classification of Diseases, a diagnostic system
developed by the World Health Organization to provide consistency throughout the world for the terms that are used to
describe medical conditions. For example, proponents of the
medical model view major depressive disorder as a disease
that requires treatment. The use of the term patient is consistent with this medical model.
Also consistent with the medical model is the use of the
term mental disorder. If you think about this term, you will
notice that it implies a condition that is inside one’s “mind.”
This term has been used historically to apply to the types of
conditions studied within psychiatry, as in the terms mental
hospital and mental health. For many professionals, though,
the term mental disorder has negative connotations, because
it has historically implied something negative. In this book,
we use the term psychological disorder in an attempt to move
away from some of the negative stereotypes associated with
the term mental disorder; we also wish to emphasize that
these conditions have an emotional aspect. For example, a
Atheoretical Orientation The authors of the DSM-IV
wanted to develop a classification system that was descriptive rather than explanatory. In the example of hypoactive
sexual desire disorder, the DSM-IV-TR simply classifies and
describes a set of symptoms without regard to their cause.
There might be any number of explanations for why a person has this disorder, including relationship difficulties, inner
conflict, or a traumatic sexual experience.
Previous editions of the DSM were based on psychoanalytic concepts and used such terms as neurosis, which implied
that many disorders were caused by unconscious conflict.
Besides carrying psychodynamic connotations, these terms
were vague and involved subjective judgment on the part of
the clinician. Neurosis is not part of the official nomenclature,
or naming system, but you will still find it in many books and
articles on abnormal psychology. When you come across the
term, it will usually be in reference to behavior that involves
some symptoms that are distressing to an individual and that
the person recognizes as unacceptable. These symptoms usually are enduring and lack any kind of physical basis. For
example, you might describe your friend as neurotic because
she seems to worry all the time over nothing. Assuming that
she recognizes how inappropriate her worrying is, your labeling of her behavior as neurotic might be justified. However, a
mental health practitioner might diagnose her as having an
anxiety disorder, a more precise description of her constant
worrying behavior. Mental health professionals still use the
term neurotic informally to refer to a person who experiences
excessive subjective psychological pain and to distinguish such
conditions from those referred to as psychotic.
The term psychosis is used to refer to various forms of
behavior involving loss of contact with reality. In other words,
a person showing psychotic behavior might have bizarre
thoughts and perceptions of what is happening. This might
involve delusions (false beliefs) or hallucinations (false perceptions). The term psychotic may also be used to refer to behavior that is so grossly disturbed that the person seems to be out
of control. Although not a formal diagnostic category, psychotic is retained in the DSM-IV-TR as a descriptive term.
Categorical Approach Implicit in the medical model is the
assumption that diseases fit into distinct categories. For example, pneumonia is a condition that fits into the category of
diseases involving the respiratory system. The DSM-IV-TR,
being based on a medical model, has borrowed this strategy.
Thus, conditions involving mood fit into the category of mood
disorders, those involving anxiety fit into the category of anxiety disorders, and so on. However, the authors of the DSMIV-TR are the first to acknowledge that there are limitations
to the categorical approach. For one thing, psychological disorders are not neatly separable from each other or from normal
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The Diagnostic and Statistical Manual of Mental Disorders 45
functioning. For example, where is the dividing line between a
sad mood and diagnosable depression? Furthermore, many
disorders seem linked to each other in fundamental ways. In a
state of agitated depression, for example, an individual is suffering from both anxiety and a sad mood.
The difficulty of establishing clear boundaries between
psychological conditions prompted the DSM-IV Task Force
to consider adopting a dimensional rather than a categorical
model. In a dimensional model, people would be rated according to the degree to which they experience a set of fundamental attributes. Rather than being classified as “depressed” or
“nondepressed,” individuals would be rated along a continuum. At one end would be no depression, and at the other
end would be severe incapacitation, with varying degrees in
between. In the current system, the many separate categories
for depressive disorders lead to a proliferation of diagnoses.
A dimensional system with numerical ratings would provide
a clearer and perhaps more accurate representation of psychological disorders.
Widiger and Samuel (2005) delineate two dilemmas
inherent in the categorical approach to diagnosis: excessive
diagnostic co-occurrence and boundary issues between diagnoses. Diagnostic co-occurrence, called comorbidity, refers to
situations in which a person experiences symptoms that meet
the diagnostic criteria for more than one disorder. Some
argue that such co-occurrence is the norm rather than the
exception. In the case of depression and anxiety, there may
be a shared negative affectivity dimension that is common
to mood disorders, anxiety disorders, and certain personality
disorders. The dilemma of problematic boundaries refers to
the overlap among several diagnoses, such as the partial
lack of distinction between oppositional defiant disorder,
attention-deficit/hyperactivity disorder, and conduct disorder.
Watson and Clark (2006) propose two possible approaches
for DSM-V. First, a reorganization of diagnostic classes would
replace the current categories with a set that reflect real-world
similarities between disorders. Second, the personality disorders would be organized along dimensions rather than in
discrete categories.
One dramatic proposal is the possibility of relinquishing
a single diagnostic scheme and instead embracing the notion
of different diagnostic systems for different purposes. In
other words, there might be two parallel systems, one for
clinicians in practice and the other for researchers in the field
of psychopathology (Watson & Clark, 2006).
During the past 30 years, significant gains have been
made in refining the psychiatric diagnostic system. With increasing experience and wisdom, however, researchers and
clinicians have come to recognize the limitations of the current system and have expressed a commitment to a significant
overhaul, such that the psychological disorders of real human
beings can be more thoughtfully understood and treated.
Multiaxial System In the DSM, diagnoses are categorized in
terms of relevant areas of functioning within what are called
axes. There are five axes, along which each client is evaluated.
An axis is a class of information regarding an aspect of an
individual’s functioning. The multiaxial system in the DSMIV-TR allows clients to be characterized in a multidimensional
way, accommodating all relevant information about their functioning in an organized and systematic fashion.
As you might imagine, when a clinician is developing a
diagnostic hypothesis about a client, there may be several
features of the individual’s functioning that are important to
capture. For most of his life, Greg has had serious personality problems characterized by an extreme and maladaptive
dependence on other people. These problems have been compounded by a medical condition, ulcerative colitis. Six months
ago, Greg’s girlfriend was killed in an automobile accident.
Before then, he was managing reasonably well, although his
personality problems and colitis sometimes made it difficult
for him to function well on his job. Each fact the client presents is important for the clinician to take into account when
making a diagnosis, not just the client’s immediate symptoms.
In Greg’s case, the symptom of depression is merely one part
of a complex diagnostic picture. As we saw earlier, most clients, such as Greg, have multiple concerns that are relevant
to diagnosis and treatment. Sometimes there is a causal relationship between comorbid disorders. For example, a man
with an anxiety disorder may develop substance abuse as he
attempts to quell the terror of his anxiety by using drugs or
alcohol. In other situations, the comorbid conditions are not
causally related, as would be the case of a woman who has
both an eating disorder and a learning disability.
The Five Axes of the DSM-IV-TR
Each disorder in the DSM-IV-TR is listed on either Axis I or
Axis II. The remaining axes are used to characterize a client’s
physical health (Axis III), extent of stressful life circumstances
(Axis IV), and overall degree of functioning (Axis V).
Axis I: Clinical Disorders The major clinical disorders are
on Axis I. In the DSM-IV-TR system, these are called
clinical syndromes, meaning that each is a collection of
symptoms that constitutes a particular form of abnormality. These are the disorders, such as schizophrenia and
depression, that constitute what most people think of as
psychological disorders. As you can see in Table 2.2, however, there are a wide variety of disorders encompassing
many variants of human behavior.
Another set of disorders in Axis I is adjustment disorders.
These are reactions to life events that are more extreme than
would normally be expected given the circumstances. To be
considered an adjustment disorder, this reaction must persist
for at least 6 months and must result in significant impairment
or distress for the individual. Adjustment disorders manifest
themselves in several forms: emotional reactions, such as anxiety and depression; disturbances of conduct; physical complaints; social withdrawal; or disruptions in work or academic
performance. For example, a woman may react to the loss of
her job by developing a variety of somatic symptoms, including
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46 Chapter 2 Classification and Treatment Plans
TABLE 2.2 Axis I Disorders of the DSM-IV-TR
Category
Description
Examples of Diagnoses
Disorders usually first
diagnosed in infancy,
childhood, or adolescence
Disorders that usually develop during the
earlier years of life, primarily involving
abnormal development and maturation
■
Learning disorders
■
Motor skills disorders, communication
disorders, pervasive developmental disorders
(e.g., autistic disorder)
■
Attention-deficit disorders and disruptive
behavior disorders
■
Feeding and eating disorders of infancy
and early childhood
■
Tic disorders
■
Elimination disorders
Delirium, dementia, amnestic,
and other cognitive
disorders
Disorders involving impairments in cognition
that are caused by substances or general
medical conditions
■
Delirium
■
Dementia (e.g., Alzheimer’s type)
■
Amnestic disorder
Mental disorders due to a
general medical condition
Conditions characterized by mental
symptoms judged to be the physiological
consequence of a general medical
condition
■
Personality change due to a general
medical condition
■
Mood disorder due to a general medical
condition
■
Sexual dysfunction due to a general medical
condition
■
Substance use disorders (e.g., substance
dependence and substance abuse)
■
Substance-induced disorders (e.g.,
substance intoxication and substance
withdrawal)
■
Schizophrenia
■
Schizophreniform disorder
■
Schizoaffective disorder
■
Delusional disorder
■
Brief psychotic disorder
■
Major depressive disorder
■
Dysthymic disorder
■
Bipolar disorder
■
Cyclothymic disorder
■
Panic disorder
■
Agoraphobia
■
Specific phobia
■
Social phobia
■
Obsessive-compulsive disorder
■
Post-traumatic stress disorder
■
Generalized anxiety disorder
Substance-related disorders
Schizophrenia and other
psychotic disorders
Mood disorders
Anxiety disorders
Disorders related to the use or abuse
of substances
Disorders involving psychotic symptoms
(e.g., distortion in perception of reality;
impairment in thinking, behavior, affect,
and motivation)
Disorders involving a disturbance in mood
Disorders involving the experience of
intense anxiety, worry, or apprehension
that leads to behavior designed to
protect the sufferer from experiencing
anxiety
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The Diagnostic and Statistical Manual of Mental Disorders 47
Category
Description
Examples of Diagnoses
Somatoform disorders
Disorders involving recurring complaints of
physical symptoms or medical concerns
not supported by medical findings
■
Somatization disorder
■
Conversion disorder
■
Pain disorder
■
Hypochondriasis
■
Body dysmorphic disorder
Conditions in which physical or
psychological symptoms are
intentionally produced in order to
assume a sick role
■
Factitious disorder
■
Factitious disorder by proxy
Disorders in which the normal integration
of consciousness, memory, identity, or
perception is disrupted
■
Dissociative amnesia
■
Dissociative fugue
■
Dissociative identity disorder
■
Depersonalization disorder
■
Sexual dysfunctions (e.g., sexual arousal disorder, orgasmic disorder, sexual pain disorder)
■
Paraphilias (e.g., fetishism, pedophilia,
voyeurism)
■
Gender identity disorder
Disorders characterized by severe
disturbances in eating behavior
■
Anorexia nervosa
■
Bulimia nervosa
Disorders involving recurring disturbance
in normal sleep patterns
■
Dyssomnias (e.g., insomnia, hypersomnia)
■
Parasomnias (e.g., nightmare disorder, sleepwalking disorder)
Disorders characterized by repeated
expression of impulsive behaviors that
cause harm to oneself or others
■
Intermittent explosive disorder
■
Kleptomania
■
Pyromania
■
Pathological gambling
■
Trichotillomania
Conditions characterized by the
development of clinically significant
emotional and behavioral symptoms
within 3 months following the onset of
an identifiable stressor
■
Adjustment disorder with anxiety
■
Adjustment disorder with depressed mood
■
Adjustment disorder with disturbance of
conduct
Conditions or problems for which a
person may seek or be referred
for professional help
■
Relational problems
■
Problems related to abuse or neglect
■
Psychological factors affecting medical
condition
■
Other conditions (e.g., bereavement,
academic or occupational problem, religious
problem, phase of life problem)
Factitious disorders
Dissociative disorders
Sexual and gender identity
disorders
Eating disorders
Sleep disorders
Impulse-control disorders
Adjustment disorders
Other conditions that may be
a focus of clinical attention
Disorders involving disturbance in the
expression or experience of normal
sexuality
Source: Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision.
Copyright © 2000 American Psychiatric Association.
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48 Chapter 2 Classification and Treatment Plans
headaches, backaches, and fatigue. A man may respond to
a diagnosis of a serious illness by becoming reckless, selfdestructive, and financially irresponsible. In these cases, the
individual’s reaction can be temporally linked to the occurrence of the life event. Moreover, the reactions are considered
out of proportion to the nature of the stressful experience.
Some conditions are the focus of clinical attention but are
not psychological disorders. In the DSM-IV-TR, these conditions are referred to as “V [vee] codes” and include a variety
of difficulties, such as relational problems, bereavement reactions, and the experience of being abused or neglected. When
these problems are the primary focus of clinical attention,
they are listed on Axis I. When these problems are evident
but are not the primary focus of concern, they are noted on
Axis IV, which you will read about later in this section.
Axis II: Personality Disorders and Mental Retardation Axis
II includes sets of disorders that represent enduring characteristics of an individual’s personality or abilities. One set of disorders is the personality disorders. These are personality traits
that are inflexible and maladaptive and that cause either subjective distress or considerable impairment in a person’s ability
to carry out the tasks of daily living. The second component
of Axis II is mental retardation. Although not a disorder in
the sense of many of the other conditions found in the DSMIV-TR, mental retardation nevertheless has a major influence
on behavior, personality, and cognitive functioning.
To help you understand the differences between Axis I and
Axis II, consider the following two clinical examples. One case
involves Juanita, a 29-year-old woman who, following the birth
of her first child, becomes very suspicious of other people’s
intentions to the point of not trusting even close relatives.
After a month of treatment, she returns to normal functioning
and her symptoms disappear. Juanita would receive a diagnosis of an Axis I disorder, because she has a condition that
could be considered an overlay on an otherwise healthy personality. In contrast, the hypersensitivity to criticism and fear
of closeness shown by Jean, another 29-year-old woman, is a
feature of her way of viewing the world that has characterized
her from adolescence. She has chosen not to become involved
in intimate relationships and steers clear of people who seem
overly interested in her. Were she to seek treatment, these longstanding dispositions would warrant an Axis II diagnosis.
An individual can have diagnoses on Axes I and II. For
example, Leon is struggling with substance abuse and is characteristically very dependent on others. Leon would probably
be diagnosed on both Axis I and Axis II. On Axis I, he would
be assigned a diagnosis pertaining to his substance abuse; on
Axis II, he would receive a diagnosis of dependent personality disorder. In other words, his substance abuse is considered
to be a condition, and his personality disorder is considered
to be part of the fabric of his character.
Axis III: General Medical Conditions Axis III is for documenting a client’s medical conditions. Although these medical
conditions are not the primary focus of the clinician, there is
At the outset of treatment, a psychotherapist strives to put the client
at ease so that a good working alliance can be established.
a solid logic for including Axis III as part of the total diagnostic picture. At times, physical problems can be the basis of
psychological problems. For example, a person may become
depressed following the diagnosis of a serious physical illness.
Conversely, such conditions as chronic anxiety can intensify
physical conditions, such as a stomach ulcer. In other cases
there is no obvious connection between an individual’s physical and psychological problems. Nevertheless, the clinician
considers the existence of a physical disorder to be critical,
because it means that something outside the psychological
realm is affecting a major facet of the client’s life.
The clinician must keep Axis III diagnoses in mind when
developing a treatment plan for the client. Take the example
of a young man with diabetes who seeks treatment for his
incapacitating irrational fear of cars. Although his physical
and psychological problems are not apparently connected, it
would be important for the clinician to be aware of the diabetes, because the condition would certainly have a major
impact on the client’s life. Furthermore, if the clinician considers recommending a prescription of antianxiety medication,
the young man’s physical condition and other medications
must be taken into account.
Axis IV: Psychosocial and Environmental Problems On Axis
IV, the clinician documents events or pressures that may affect
the diagnosis, treatment, or outcome of a client’s psychological