Classification of Psychological Disorders

Learning Objectives

Importance of Classification Philosophical underpinnings of two

approaches to classification Purposes of Classification

Symbols and Language

Words are symbols By convention we all agree on symbols Why I can refer to a pen and we all

know what it is I am referring to If not, have to have pen directly in front

of us. How do we come to establish symbols

or concepts that everyone can agree upon?

Nature of classification

Classification

Important activity in clinical work and research

Basic part of science Information made more accessible,

meaningful, and less cumbersome

Classification

Normal vs. Abnormal

Charles Manson

Classification

Need to further define abnormal Divide “abnormal” into subclasses Mushroom example

MushroomNot a Mushroom

Poisonous Edible

Bach Mai Hospital doctors treat the oldest of two brothers who survived eating poisonous mushrooms, although six of their families members did die.

Classification Historical

Paradigms have influenced how classification done and what was classified

Hippocrates’ Four humors:

Hippocrates

1. Black Bile ---- Depression 2. Yellow Bile ---- Tension/Anxiety 3. Phlegm ---- Dull, Sluggishness 4. Blood ---- Mania/Mood Swings

Historical

Pre-history: Likely simply divided into normal vs abnormal

Ancient Greece: Hippocrates Others over the ages: Jean Fernel

(1497 – 1588); Feliz Platter (1536-1614); Francois Baussier de Sauvages (18thC)

Philosophical Issues in Abnormal Behaviour

Paradigms Nature of psychopathology,

normalcy, belief in paradigm Historical

– Emil Kraeplin and Neo-Kraeplians– Sigmund Freud

Contemporary: – DSM & ICD– PDM & OPDS

Two Trends

Symptom as Focus (Kraeplin) Underlying Cause as Focus (Freud)

Symptom as Focus

Group of Sx or observable behaviors Seen as cause of the difficulties Focus of assessment and treatment is

on eradicating the symptoms Behavior school, ICD, DSM Variant embraced by Managed Care in

US (i.e., insurance company)

Underlying Cause as Focus

Problems caused by underlying process

Assessment and treatment focuses on underlying process

Orientation of psychodynamic, cognitive behavioral (to degree), and PDM.

Classification

Basic part of science Want to make information more

accessible, meaningful, and less cumbersome

Classification - Purposes

Description and need to identify Communication Research Treatment Insurance Theory Development Epidemiological Information

Diagnosis leads to treatment From medical perspective:

Appendicitis Gas Pains

Diagnosis does not always lead to proper treatment:

– Alzheimer’s Disease– Depression and “families” of drugs– ALS

How to Classify?

1. Divide disorders into mutually exclusive and collectively exhaustive subclasses

a. Mutually Exclusive: disorders should be distinct and cannot belong to two different subclasses (e.g., poisonous and edible mushrooms???)

b. Collectively Exhaustive: all disorders must be classified

How to Classify? Cont’d

2. Subclasses defined by necessary and sufficient conditions

a. Must be characteristics that are necessary for classification

b. Must also be set of sufficient conditions to belong to a subclass

How to Classify Cont’d

Reliability: Each time you (or someone else) uses the classification system, should get the same result– Need to identify psychological problems in a

clear and reliable manner– Also need agreement among mental health

professionals or can have individuals referring to same term to describe different disorders

E.G., Schizophrenia and “split personality” (i.e., dissociative identity disorder)

How to Classify Cont’d

Validity: Classification system should say something about the “true world”

DSM – IV Text Revision

DSM’S

Categorical Approach to define abnormality

Revised periodically:– DSM first published 1952– DSM II published 1968– DSM III published 1980– DSM III Revised published 1987– DSM IV published 1994– DSM IV Text Revision 2000– DSM V published 2014

DSM

Over 400 disorders DSM provides descriptive

information not based on any one theoretical perspective (although this is debateable)

Categorical Approach Descriptive features are based on

observable features:

DSM IV TR

Provides information on:– Diagnostic Features– Associated Features and Disorders– Associated Laboratory Findings– Age-related, Culture-related and

Gender-related features

DSM 4 & 5

DSM 4 – 5 axes

DSM 5 - No Axes – Different Disorders

Pros and Cons

Pro:– Reliability has improved over previous

editions– Provides information on research and

reliable and valid information– Axis IV and V very good in terms of

attempting to take into account many factors

Pros and Cons

Con:– Only first 3 Axes tend to used and

even then Axis 2 used inappropriately– Labeling and stigma still issue– Biological tests not used– Fees paid based on diagnosis and

some patients diagnosed inappropriately

– Doesn’t lead to differential treatment decisions for most part

– Still very subjective

DSM IVTR (p. XXXIV)

“ DSM-IV is a categorical classification that divides mental disorders into types based on criteria sets with defining features….. In DSM-IV there is no assumption that each category of mental disorder is a completely discrete entity with absolute boundaries dividing it from other mental disorders or from no mental disorder”

Diagnosis and Formulation

Diagnosis: Assigning diagnostic category

Formulation: Attempt to explain genesis, maintenance, and process related information for treatment

Struct. Interview Diagnosis Assessment Formulation

Most clinicians agree that need both, although likely majority indicate that formulation is actually more important

Other Diagnostic Manuals in Use

Other Diagnostic Manuals in Use

Psychodynamic Diagnostic Manual (PDM)

PDM

DSM provides one level of description– Some argue don’t measure some of the

most important things PDM:

– there is more to people than what is described in DSM

– Attempts to describe and categorize elements not found in DSM

– Attempts to provide information that will improve comprehensive treatments

PDM

Not developed to supplant DSM but to supplement DSM

Developed from a theoretical perspective: Current Psychodynamic Theory:– Psychoanalysis– Object Relations– Attachment Theory

PDM

Diagnostic framework Describes the whole person:

– Surface and deeper levels of personality, person’s emotional and social functioning

– Based on current neuroscience and treatment outcome studies

PDM Developed By

American Psychoanalytic Association

American Academy of Psychoanalysis

International Psychoanalytic Association

American Psychological Association Division 39

National Membership Committee on Psychoanalysis in Clinical Social Work

PDM

The elements include:– Personality patterns– Social and emotional capacities– Unique mental profiles– Personal experiences of individuals

PDM- Rationale

Human behaviour is complex DSM simplifies behaviour too much Want to direct focus on full range

of affect, thought, behaviour in context of an individual’s own unique history

PDM- Rationale Cont’d

Consistent with idea that: Rather than thinking of

people having discrete disorders (i.e., ego dystonic, separate, outside of self), see disorders as result of some process (personality, incorporation of upbringing, etc.) and the process is what is important

PDM Dimensions

1. Personality Patterns and Disorders (P Axis)

2. Mental Functioning (M Axis)3. Manifest Symptoms and Concerns

(S Axis)

P Axis

Person’s location on Continuum: Healthy -----------------Disordered

Ways in which person organizes mental functioning and interacts with world

Maxim: Need to understand person in order to understand problem

P Axis

Includes many of the Axis II diagnoses from DSM

Adds other ones that are seen as extremely important:– Depressive Personality Disorder– Sadistic and Sadomasochistic PD– Masochistic (Self-defeating) PD– Somatizing PD– Dissociative PD

M Axis

Detailed look at emotional functioning– E.G., Information processing, self-

regulation, relationships, emotional expression, learning, coping/defenses, etc.

S Axis

Using the DSM categories, focus on personal experience of difficulties

Need to be seen in context of personality and mental functioning

PDM

Attempt to develop a thorough and comprehensive diagnostic picture

Takes whole person into account

PDM

Published in 2006 so little early to evaluate

Welcomed by most clinicians as an addition to aid in treatment planning

Aids in formulation:– Diagnosis doesn’t give you all relevant

information for treatment– Need to determine etiology, maintenance

factors, process-related issues, history of relationships, etc. which guide treatment

Other Classification Systems ICD – 10 McLemore and Benjamin’s

Interpersonal Diagnosis Operationalised Psychodynamic

System

Classification

Discrete?– Can people be placed in a neat

diagnostic box or not?

Discrete Categories

Female

Not Pregnant

Male

Pregnant

Classification

Continuous?– Are the disorders on a continuum?

Nondepressed Depressed

Discrete Categories?

Not Depressed

Abnormal

Depressed

Normal