Abnormal Psychology - Clinical Persps. on Psych. Disorders, 6th ed. - R. Halgin, et. al., (McGraw-Hill, 2010 WW-71-75

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44 Chapter 2 Classifi cation and Treatment Plans

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 theoreti- cal basis of the classifi cation system. Each edition of the manual has represented thousands of hours of discussion among experts in several related fi elds from different theo- retical 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 classifi cation 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 Classifi cation of Diseases, a diagnostic system developed by the World Health Organization to provide con- sistency 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

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?

Atheoretical Orientation The authors of the DSM-IV wanted to develop a classifi cation system that was descriptive rather than explanatory. In the example of hypoactive sexual desire disorder, the DSM-IV-TR simply classifi es 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 diffi culties, inner confl ict, or a traumatic sexual experience.

Previous editions of the DSM were based on psychoana- lytic concepts and used such terms as neurosis, which implied that many disorders were caused by unconscious confl ict.

Besides carrying psychodynamic connotations, these terms were vague and involved subjective judgment on the part of the clinician. Neurosis is not part of the offi cial nomenclature, or naming system, but you will still fi nd 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 label- ing of her behavior as neurotic might be justifi ed. 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, psy- chotic is retained in the DSM-IV-TR as a descriptive term.

Categorical Approach Implicit in the medical model is the assumption that diseases fi t into distinct categories. For example, pneumonia is a condition that fi ts 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 fi t into the category of mood disorders, those involving anxiety fi t into the category of anxiety disorders, and so on. However, the authors of the DSM- IV-TR are the fi rst 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

Severe depression can be so devastating that some people consider suicide their only option.

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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 suf- fering from both anxiety and a sad mood.

The diffi culty 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 accord- ing to the degree to which they experience a set of fundamental attributes. Rather than being classifi ed as “depressed” or

“nondepressed,” individuals would be rated along a contin- uum. 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 defi ant disorder, attention-defi cit/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 refl ect 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 fi eld of psychopathology (Watson & Clark, 2006).

During the past 30 years, signifi cant gains have been made in refi ning the psychiatric diagnostic system. With in- creasing experience and wisdom, however, researchers and clinicians have come to recognize the limitations of the current system and have expressed a commitment to a signifi cant 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 fi ve 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 DSM- IV-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 com- pounded 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 diffi cult for him to function well on his job. Each fact the client pre- sents 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 abnormal- ity. 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 signifi cant 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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■ Learning disorders

■ Motor skills disorders, communication disorders, pervasive developmental disorders (e.g., autistic disorder)

■ Attention-deﬁ cit disorders and disruptive behavior disorders

■ Feeding and eating disorders of infancy and early childhood

■ Tic disorders

■ Elimination disorders TABLE 2.2 Axis I Disorders of the DSM-IV-TR

Category Description Examples of Diagnoses

Disorders usually ﬁ rst diagnosed in infancy, childhood, or adolescence

Disorders that usually develop during the earlier years of life, primarily involving abnormal development and maturation

■ Delirium

■ Dementia (e.g., Alzheimer’s type)

■ Amnestic disorder Delirium, dementia, amnestic,

and other cognitive disorders

Disorders involving impairments in cognition that are caused by substances or general medical conditions

■ Personality change due to a general medical condition

■ Mood disorder due to a general medical condition

■ Sexual dysfunction due to a general medical condition

Mental disorders due to a general medical condition

Conditions characterized by mental symptoms judged to be the physiological consequence of a general medical condition

■ Substance use disorders (e.g., substance dependence and substance abuse)

■ Substance-induced disorders (e.g., substance intoxication and substance withdrawal)

Substance-related disorders Disorders related to the use or abuse of substances

■ Schizophrenia

■ Schizophreniform disorder

■ Schizoaffective disorder

■ Delusional disorder

■ Brief psychotic disorder Schizophrenia and other

psychotic disorders

Disorders involving psychotic symptoms (e.g., distortion in perception of reality;

impairment in thinking, behavior, affect, and motivation)

■ Major depressive disorder

■ Dysthymic disorder

■ Bipolar disorder

■ Cyclothymic disorder Mood disorders Disorders involving a disturbance in mood

■ Panic disorder

■ Agoraphobia

■ Speciﬁ c phobia

■ Social phobia

■ Obsessive-compulsive disorder

■ Post-traumatic stress disorder

■ Generalized anxiety disorder Anxiety disorders 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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Source: Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision.

■ Factitious disorder

■ Factitious disorder by proxy Factitious disorders Conditions in which physical or

psychological symptoms are intentionally produced in order to assume a sick role

■ Dissociative amnesia

■ Dissociative fugue

■ Dissociative identity disorder

■ Depersonalization disorder Dissociative disorders Disorders in which the normal integration

of consciousness, memory, identity, or perception is disrupted

■ Sexual dysfunctions (e.g., sexual arousal disorder, orgasmic disorder, sexual pain disorder)

■ Paraphilias (e.g., fetishism, pedophilia, voyeurism)

■ Gender identity disorder Sexual and gender identity

disorders

Disorders involving disturbance in the expression or experience of normal sexuality

■ Anorexia nervosa

■ Bulimia nervosa Eating disorders Disorders characterized by severe

disturbances in eating behavior

■ Dyssomnias (e.g., insomnia, hypersomnia)

■ Parasomnias (e.g., nightmare disorder, sleep- walking disorder)

Sleep disorders Disorders involving recurring disturbance in normal sleep patterns

■ Intermittent explosive disorder

■ Kleptomania

■ Pyromania

■ Pathological gambling

■ Trichotillomania Impulse-control disorders Disorders characterized by repeated

expression of impulsive behaviors that cause harm to oneself or others

Category Description Examples of Diagnoses

■ Adjustment disorder with anxiety

■ Adjustment disorder with depressed mood

■ Adjustment disorder with disturbance of conduct

Adjustment disorders Conditions characterized by the development of clinically signiﬁ cant emotional and behavioral symptoms within 3 months following the onset of an identiﬁ able stressor

■ 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)

Other conditions that may be a focus of clinical attention

Conditions or problems for which a person may seek or be referred for professional help

■ Somatization disorder

■ Conversion disorder

■ Pain disorder

■ Hypochondriasis

■ Body dysmorphic disorder Somatoform disorders Disorders involving recurring complaints of

physical symptoms or medical concerns not supported by medical ﬁ ndings

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headaches, backaches, and fatigue. A man may respond to a diagnosis of a serious illness by becoming reckless, self- destructive, and fi nancially 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 diffi culties, 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 character- istics of an individual’s personality or abilities. One set of disorders is the personality disorders. These are personality traits that are infl exible 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 DSM- IV-TR, mental retardation nevertheless has a major infl uence 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 fi rst 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 long- standing 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 char- acteristically 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 docu- menting a client’s medical conditions. Although these medical conditions are not the primary focus of the clinician, there is

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

At the outset of treatment, a psychotherapist strives to put the client at ease so that a good working alliance can be established.