CHAPTER FOUR
Classification of Abnormal Behavior
Classification

Classification (what it is and why we do it)

Classification systems

Description of the DSM-IV

Evaluation of the DSM-IV

Limitations of DSM-IV
YOU ARE NOT RESPONSIBLE FOR THE
ASSESSMENT SECTION
Classification

Classification (what it is and why we do it)

Classification systems

Description of the DSM-IV

Evaluation of the DSM-IV

Limitations of DSM-IV
What is classification?

Classification
 subdividing or organizing a set of related
objects

Animals, Historical Periods, and Music
are subdivided and organized in various
ways
Why use a classification
system?

Benefit
 a shared scientific language
 facilitates description
 aids treatment decisions, prognosis
 facilitates research on etiology, treatment
outcome
 facilitates 3rd-party reimbursement
(managed care system)
Why use a classification
system?

Concerns
 stigmatization and marginalization
 expectations for behavior may change as
result
 unrelated problems may be misattributed to
diagnosis
Rosenhan’s Study
Classification

Classification (what it is and why we do it)

Classification systems

Description of the DSM-IV

Evaluation of the DSM-IV

Limitations of DSM-IV
Describing Classification
Systems
What do the items in each group have in common?
1
2
DIAMOND
3 Stroke
COAL
Heart Attack
Categories vs. Dimensions

Categorical Approach
 reflects a difference in
kind or quality

Dimensional Approach
 focuses on the amount
of a particular
characteristic an object
possesses
H
E
I
G
H
T
Approaches to Classifying
Abnormal Behavior

Categorical Approach
 people with abnormal behaviors are
qualitatively different from normal people
(discrete groups)
not depressed | depressed
Are you Depressed?
 Yes
 No
Categorical Approach
80
percent
60
40
20
35
65
0
depressed?
depressed
not depressed
Approaches to Classifying
Abnormal Behavior

Dimensional Approach
 people with abnormal behaviors are
quantitatively different (continuum)
very depressed
mildly depressed
not at all depressed
X=?
How Depressed
are you?
0
Not at all
1
2
3
4
Extremely
Approaches to Classifying
Abnormal Behavior

Threshold Approach
 combines categorical and dimensional
very depressed
mildly depressed
not at all depressed
X
How Depressed
are you?
0
1
2
Not at all
Legend:
0-1 = Not Depressed
2 and above = Depressed
3
4
Extremely
Classification

Classification (what it is and why we do it)

Classification systems

Description of the DSM-IV

Evaluation of the DSM-IV

Limitations of DSM-IV
Description of DSM-IV
System

Depends on observations and
descriptions, rather than causes, which
are often unknown

Categorical

Multi-Axial
Description of DSM-IV
System

Axis I -- Clinical disorders
 mostly characterized by episodic periods of
psychological turmoil

Axis II -- Personality disorders and
mental retardation
 mostly concerned with stable, longstanding
problems
Description of DSM-IV
System

Axis III -- General Medical Conditions
 conditions relevant to etiology of patient’s
behavior or treatment program

Axis IV -- Psychosocial & Environmental
Problems
 factors that may affect the treatment and
prognosis of mental disorder
Description of DSM-IV
System

Axis V -- Global Assessment of
Functioning
 rating of 1 to 100 of individual’s overall
level of functioning
 usually assessed at several points
• highest in last year
• at intake
• Current
The only axis that is dimensional

90 -100
– Superior functioning in a wide range of activities,
life’s problems never seem to get out of hand, is
sought out by others because of his or her many
positive qualities. No symptoms

51-60
– Moderate symptoms (e.g., flat affect and
circumstantial speech, occasional panic attacks) OR
moderate difficulty in social, occupational, or school
functioning (e.g., few friends, conflicts with peers or
co-workers)

1-10
– Persistent danger of severely hurting self or others
(e.g., recurrent violence) OR persistent inability to
maintain minimal personal hygiene or serious suicidal
act with clear expectation of death
DSM-IV TR:
Hypothetical Example
Axis I: Major Depression, Recurrent, Mild
Axis II: No diagnosis, frequent use of denial
Axis III: Recurrent ear infections
Axis IV: Victim of child neglect, 3 younger sibs
Axis V: GAF = 56 (current)
Remember Gary?
DSM-IV: A 5-Axis System
The Case of “Gary”
Axis I: R/O Major depressive disorder
Axis II: Schizoid personality disorder
Axis III: Arrhythmia
Axis IV: Problems related to the social
environment
Axis V: 60 (current)
Hypothetical Example 2
Rule out
specifiers
Axis I: Major Depression, Recurrent, Mild
Alcoholism, in remission
Bulimia Nervosa (provisional)
Axis II: R/O Borderline Personality Disorder
Axis III: Ovarian Cancer
Axis IV: sexually abused as a child, rape-victim
Axis V: GAF = 45 (at intake)
Classification

Classification (what it is and why we do it)

Classification systems

Description of the DSM-IV

Evaluation of the DSM-IV

Limitations of DSM-IV
Evaluation of DSM-IV

Reliability
 consistency of
measurements, including
diagnostic decisions
Reliability
Test
Clinician
Observed/Predicted Outcome
Test score or performance
Diagnosis
Evaluation of DSM-IV

Inter-rater Reliability
 refers to agreement of raters about
observations
Evaluation of DSM-IV
 Validity
 meaning or importance of a classification
system
 conceptualized as a continuum of more to
less useful (i.e., classification systems are
more to less valid)
 But valid for what?
 We need to ask… how meaningful is it for a
desired purpose?
 Is the SAT valid?
 (if we’re assessing aptitude, not artistic abilities)
Reliable and Valid?
1
2
LARRY
3
CURLY
MO
Validity Illustration
Cook Book A
Cook Book B
Apple Pie:
apples, sugar,
flour, cinnamon
Apple Pie:
apples, tomatoes,
lettuce, flour
Burritos:
beans, tortillas,
tomatoes, lettuce
Burritos:
beans, cinnamon,
tortillas, sugar
ICD10-DCR
PTSD
DSM-IV
A. Exposure to stressor
A1. Exposure to stressor
A2. Emotional reaction to stressor
B. Persistent remembering of the stressor in one
of: intrusive flashbacks, vivid memories or
recurring dreams, experiencing distress
when reminded of the stressor
Requires one or more of:
B1. Intrusive recollections
B2. Distressing dreams
B3. Acting/feeling as though event were recurring
B4. Psychological distress when exposed to reminders
B5. Physiological reactivity when exposed to reminders
C. Requires only one symptom of actual or
preferred avoidance
Requires three or more symptoms of:
C1. avoidance of thoughts, feelings or conversations
associated with the stressor
C2. avoidance of activities, places or people associated
with the stressor
C3. inability to recall
C4. diminished interest in significant activities
C5. detachment from others
C6. restricted affect
C7. sense of foreshortened future
Either of D1 orD2:
D1 inability to recall
D2 two or more of:
A. sleep problems
B. Irritability
C. concentration problems
D. Hypervigilance
E. exaggerated startle response
E. Onset of symptoms within 6 months of the
stressor
Two or more of:
D1. sleep problems
D2. irritability
D3. concentration problems
D4. hypervigilance
D5. exaggerated startle response
E. Duration of the disturbance is at least 1 month
F. Requires distress or impairment
Validity & Evaluation of
DSM-IV

Types of Validity
 Etiological
 Concurrent
 Predictive
Validity & Evaluation of
DSM-IV

Etiological Validity
 concerned with the specific factors that are
regularly and perhaps uniquely associated
with a particular disorder
Etiological Validity
Classification System 1
Cause
A
B
C
D
Disorder
A1
B1
C1
D1
Classification System 2
Cause
A
B
C
D
Disorder
A1
B1
C1
D1
Validity & Evaluation of
DSM-IV

Concurrent Validity
 concerned with the present time and the
association between disorder and other
symptoms, life events and test performance
Validity & Evaluation of
DSM-IV

Predictive Validity
 concerned with the accuracy of predicting
future treatment and treatment outcomes
Classification

Classification (what it is and why we do it)

Classification systems

Description of the DSM-IV

Evaluation of the DSM-IV

Limitations of DSM-IV
Limitations of the DSM-IV

Arbitrary boundary between normal and
abnormal behavior
 Cutoff points not always empirically
justified
 Reliance on clinicians’ subjective judgment
 Time periods in definitions of diagnoses
Limitations of the DSM-IV

Problem of Comorbidity
 Simultaneous appearance of two or more
disorders in the same person
 56% of those who meet criteria for one
disorder also meet criteria for at least one
other disorder
 Comorbidity affects validity of the system and
the reliability of diagnosis
Last Word on Classification
(for now)

Beware of “Intern's
Syndrome”
Tendency to diagnose one's self while
studying any particular disorder (“I do
that!”)
 look at frequency and severity of
symptoms, as well as number of
symptoms
 check in with friends and or
professionals about how you're
doing
Optional Slides
Categorical Approach
75
percent
50
25
50
50
0
depressed?
depressed
not depressed
Categorical Approach
75
percent
50
25
60
40
0
depressed?
depressed
not depressed