Chapter 3 –
Classification and
Diagnosis
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How do we understand the
individual person?
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Each mental patient is unique and presents a
combination of genetic factors, life experiences, and
current circumstances that affect behavior
We need to assess individual factors but at the
same time compare this patient’s behavior to a
general body of knowledge based on the
investigation of may people with similar symptoms
We search for common patterns of behavior that
would enable us to assign this patient to a category
of mental illness .That is, to classify.
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Important Aspects of a
Classification Scheme
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Classification: a way for scientists to organize,
describe, and relate the subject matter of their
discipline
Validity: whether a classification scheme is accurately
capturing reality
Utility: how useful a classification scheme is
Diagnosis system: a classification based on rules
used to organize and understand diseases and
disorders
When the rules are applied to the symptoms of one
person we get a diagnosis for the symptoms in this
person
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Important Aspects of a
Classification Scheme
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Categorical approach: an object is determined to be a
member of a category or not (e.g., depressed or not
depressed); Qualitative difference between the
various categories
Dimensional approach: an object differs in degree
from others – a continuum (e.g., mildly depressed,
moderately depressed, severely depressed)
Prototype model: members of a category may differ
in degree to which they represent a common
example (used in DSM); this is a quantitative
approach – members differ in quantity- how much
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the have of the dimension (e.g. depression)
rights reserved.
An examples of a Dimensional
Approach
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Thomas Achenbach identified two
broad dimensions of behaviors in
children:
Externalizing and Internalizing
The child’s behavior can be described
on the basis of the intensity of the
externalizing or internalizing behaviors
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The Purpose of a Diagnostics System for
Mental Disorders
(Exhibit 3.1 p. 67)
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Provide a description of the patient’s condition
Reflect the best scientific knowledge of
psychopathology
Provide a common language for mental health
professional and also patients
Indicate possible causes (etiology)
Indicate possible outcomes (prognosis)
Provide guidance on co-existence
Provide guidance on treatment option
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Defining Abnormal Behavior
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What is abnormal? Many factors need to be
considered including:
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The cultural and societal context
Whether there is distress or discomfort
Whether the problem is harming others
How common the problem is
How much it is interfering with a person’s ability to
function
– If it is common for that person’s developmental
stage (developmental psychopathology)
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Diagnosis and Defining
Disorder
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No diagnosis is based on a single symptom
DSM-IV-TR defines disorder in a complicated
fashion including
– Symptoms associated with distress or
impairment/disability
– Increased risk of suffering
– Culturally atypical
– Not just deviant behavior (unless there is also
dysfunction)
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Developmental Psychopathology
Common in Child Assessment
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Developmental psychopathology is an
approach to describing and studying
disorders of childhood and adolescence in a
way that stresses the importance of
developmental processes and tasks
One needs to be familiar with the sequence
and the timing of developmental milestones
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Developmental Psychopathology
(cont-d)
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To understand maladaptive behavior,
one must view it in relation to what is
considered normative
Abnormal development involves
continuities and discontinuities, with
both quantitative and qualitative
changes in patterns of behavior over
time
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Diagnosis and Defining Disorder
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Wakefield – Harmful Dysfunction: the
problem must be clear and there must be
harm to person or others
Dyscontrol: impairment must be involuntary
or not readily controlled
Diagnosis criteria always include a cluster of
symptoms (a syndrome) that co-occur
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The Development of Disorders
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Most all contemporary models are
biopsychosocial – but different theories
represent different emphases
Some models emphasize biological aspects
while others emphasize psychological or
social aspects
Life stress model – important impact of the
number of life stressors on the development
of disorders
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The DSM Approach to
Diagnosis: History
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First edition of DSM (1952) had fairly vague
terms and emphasized psychodynamic
contributions
DSM-II (1968) was less psychodynamically
focused as medications were more commonly
being used
DSM-III (1980) guided by Robert Spitzer, was
atheoretical (revision done in 1987)
– Focus on diagnostic criteria, multiaxial, increase in
focus on reliability Copyright © 2014 John Wiley & Sons, Inc. All
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The DSM Approach to
Diagnosis: History
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DSM-IV (1994)
– Further focus on reliability
– ‘Work groups’ worked on clusters of disorders
– Text revision (diagnostic criteria unchanged) DSMIV’TR’ completed in 2000
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DSM-5 (2013) – Current Diagnostic Manual
– Removed some categories and diagnoses, added
others
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The DSM Approach to
Diagnosis
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DSM-5
– Defines a mental disorder as …”a syndrome
characterized by clinically significant disturbance in
an individual’s cognition, emotion regulation, or
behavior that reflects a dysfunction in the
psychological, biological, or developmental
processes underlying mental functioning.”
– Associated with distress or disability
– Culturally expected response is not a mental
disorder
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The DSM Approach to
Diagnosis
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DSM-5 Some Changes
– Many disorders are now grouped differently (e.g.,
depression, anxiety, and somatic disorders are
grouped as internalizing disorder)
– Personality disorders, childhood disorders are not
separated from other disorders as in previous
versions
– Controversy in many of the changes, including
how reliable they are, what defines a diagnosis,
and what diagnoses were removed/changed
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The DSM Approach to
Diagnosis
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Importance of considering culture
– Information in the text on cultural variation
– Cultural bound syndromes
– Diagnosis should not occur if symptoms are
culturally typical
– Diagnosis must be done in a culturally sensitive
context
– Section on cultural formulation
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Attending to cultural identity
Cultural explanations for disorder
Cultural relationships with client and clinician
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The DSM Approach to Diagnosis
Problems/Limitations
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Comorbidity: when a person receives two
diagnoses at once
– DSM attempts to decrease the likelihood of this
with several exclusionary rules
– However, comorbidity is very common in the DSM
(previous estimates >40%)
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Diagnoses do not account for normal
reactions to life stressors (e.g., divorce,
terminal illness)
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The DSM Approach to Diagnosis
Problems/Limitations
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Diagnostic criteria seem to include too much of
the population (sometimes 25-30% of the
population)
Although better than the earlier versions DSM
diagnoses are not as reliable as hoped (may be
due to reliance on categories)
Heterogeneity of symptom profiles is
problematic
Polythetic nature of disorders: same diagnosis
can be applied to similar and different symptoms
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The DSM Approach to Diagnosis
Problems/Limitations
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Validity of some disorders is questionable
(i.e., that the diagnosis is a discrete entity)
Current research indicates that some
disorders may be both a category and a
continuum (e.g., depression)
Resilience is often not included in
understanding disorders, yet is a common
aspect of human functioning
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Other Classification Schemes
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International Statistical Classification of
Diseases and Related Health Problems (ICD10) – developed by World Health Org.
– Mental and behavioral disorders subsection
(compatible with the DSM-IV)
– Companion “International Classification of
Functioning, Disability and Health (ICF)” focused
on overall functioning and health
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Achenbach System of Empirically Based
Assessment – internalizing/externalizing
problems
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