DSMIVTR

1
DSM-IV-TR

• 6.16.2004

2
Activity

• It is 2036 and the space probe Athena has
  identified life on a distant planet. Using
  cutting edge technology, Athena has sent pictures
  and descriptions of the various aliens living on
  this planet back to Earth. You have been asked
  to partake in a task force designed to create a
  classification system for these aliens. The
  purpose of this classification system will be
  two-fold to organize our knowledge and enhance
  communication through consensus.

3
Tasks

• 1. Use the information about the aliens to
  create a classification system that uses at least
  3, but no more than 5 groups (or categories).
• 2. Give each classified group of aliens a name
  and identify the characteristics that distinguish
  them from the other groups.

4
Review Operationalizing mental illness

• Why do we do it?
• Nomenclature, consensus, communication,
  organization, research, treatment

5
Operationalizing mental illness

• Objectivity and measurability
• Validity
• Reliability
• Must use observable phenomenon such as
• Physical symptoms (eg. heart palpitations,
  insomnia, etc.)
• Psychological symptoms (eg. delusions, memory
  loss, etc.)
• Mood (eg. fear, elation, anxiety, etc.)
• Behavior (eg. self-mutilation, purging, etc.)

6
Have we been able to operationalize mental
disorders?

• Diagnostic and Statistical Manual of Mental
  Disorders, Fourth Edition, Text Revision
• Published by the American Psychiatric Association
• Primarily used in the United States
• Includes information only on mental illnesses
• Classifies mental illnesses into different types
  of disorders (Mood disorders, psychotic
  disorders, eating disorders, etc.)
• International Classification of Diseases (ICD)
• Created by the World Health Organization
• Used throughout the rest of the world
• Includes information on both mental and physical
  illnesses

7
What is the DSM-IV-TR?

• Contains
• Diagnostic criteria
• Associated features (eg. other symptoms may be
  present, but which are not necessary for a
  diagnosis)
• Age of onset
• Typical course of illness
• Prevalence rates specific to age, gender, and
  ethnicity
• Does not contain
• Information about etiology
• Information about treatment
• Cultural implications

8
Multiaxial Classification

• Axis I Episodic disorders, adult onset
• Axis II Chronic, pervasive disorders, childhood
  disorders
• Axis III Medical conditions
• Axis IV Sociocultural stressors
• Axis V Global Assessment of Functioning
• 1-100 rating scale (1bad, 100good)

9
Global Assessment of Functioning

• 100 Superior functioning in a wide range of
  activities, lifes problems never seem to
  get out of hand, no symptoms, etc.
• 80 If symptoms are present, they are transient
  and expectable reactions to psychosocial
  stressors, no more than slight impairment in
  functioning (falling behind in schoolwork)
• 60 - Moderate symptoms or moderate impairment in
  functioning (conflicts with coworkers, some
  panic attacks)
• 40 - Some impairment in reality testing or
  communication or major impairment in functioning
  (speech is sometimes illogical or obscure,
  failing school, unable to hold a job,
• 20 - Some danger of hurting self or others or
  occasionally fails to maintain minimal personal
  hygiene or gross impairment in communication
  (suicide, violent, smears feces, mute, etc.)

10
Examples

• Axis I Major Depressive Disorder
• Alcohol Abuse
• Axis II Dependent Personality Disorder
• Axis III None
• Axis IV Unemployment
• Axis V GAF 35 (on admission)
• GAF 57 (at discharge)
• What does this tell us about this person?
• What does this not tell us about this person?

11
Examples

• Axis I Post-Traumatic Stress Disorder
• Social Phobia
• Axis II None
• Axis III Hypothyroidism
• Axis IV Victim of child abuse
• Axis V GAF 65 (current)
• What does this tell us about this person?
• What does this not tell us about this person?

12
Assumptions of the DSM

• Each diagnosis is unique and distinct
• One diagnosis over a lifespan
• Little comorbidity (i.e. having one disorder
  shouldnt affect the probability that a person
  would have another disorder)
• Homogeneity the disorder manifests itself the
  same way in everyone (all people with the
  disorder have similar symptoms, follow a similar
  course, etc.)
• It should allow one to distinguish between people
  who do and do not have the disorder

13
How was the DSM developed?

• DSM-I (1952)
• Created around the same time as ICD-6
• Purpose create a classification that was a
  consensus of contemporary thinking
• Diagnoses were created by committees and revised
  by 10 of the members of the American
  Psychological Association
• Included approximately 60 disorders
• Definitions were vague, wordy descriptions
• Based on psychoanalytic theory

14
How was the DSM developed?

• DSM-II (1968)
• Created around the same time as ICD-8
• Purpose created to promote international
  consensus in the realm of mental health
• Similar to DSM-I in terms of its development and
  the presentation of disorders
• 180 disorders were included
• Homosexuality was included as a psychological
  diagnosis

15
How was the DSM developed?

• DSM-III
• First attempt to use research in the development
  of diagnostic categories, but still mostly based
  on clinical judgment
• Definitions were changed to be more specific
• Both inclusion and exclusion criteria
• Homosexuality no longer considered a mental
  disorder

16
How was the DSM developed?

• DSM-IV-TR
• Attempted to systematize the way diagnostic
  criteria are developed
• 175 psychologists did literature reviews of the
  research on each diagnosis
• Field trials were conducted that tested the
  reliability of the diagnoses
• There is still the criticism that the diagnoses
  are based on the clinical judgment of a few
  psychologists in the individual field
• Added Culture Bound Syndromes to address cultural
  differences in presentation of symptoms

17
Evolution of Diagnoses

• Example DSM-I Borderline Personality disorder
• characterized by brief but nonreactive mood
  swings, both depressive and hypomanic, in the
  context of a chronically maladaptive personality
  resembling hysterical character.

18
Evolution of Diagnoses

• Example DSM-IV-TR Borderline Personality
  disorder
• A pervasive pattern of instability of
  interpersonal relationships, self-image, and
  affects, and marked impulsivity beginning by
  early adulthood and present in a variety of
  contexts, as indicated by 5 or more of the
  following
• Frantic efforts to avoid real or imagined
  abandonment
• Pattern of unstable and intense interpersonal
  relationships characterized by alternating
  extremes of idealization and devaluation
• Markedly and persistently unstable self-image or
  sense of self
• Impulsivity in at least two areas that are
  potentially self-damaging
• Recurrent suicidal behavior, gestures, threats,
  or self-mutilation
• Affective instability due to a marked reactivity
  of mood
• Chronic feelings of emptiness
• Inappropriate, intense anger, or difficulty
  controlling anger
• Transient, stress-related paranoid ideation or
  severe dissociative symptoms

19
Evaluation of the DSM-IV-TR

• Does it do what it is supposed to?
• Is each diagnosis unique and distinct???
• Fluidity of diagnoses transition from one
  diagnosis to another
• 25 of AN patients develop BN
• Comorbidity
• Two or more disorders occurring in the same
  individual
• 91 of people with Schizophrenia had at least one
  other diagnosis
• 77 of people with BN had at least one other
  diagnosis
• 75 of people with MDD had at least one other
  diagnosis
• Disorders co-occur at rates greater than expected
  by chance alone
• Depression and Anxiety disorders
• Substance abuse and Antisocial Personality
  Disorder

20
Evaluation of the DSM-IV-TR

• Does homogeneity occur? Do all people with the
  disorder have similar symptoms, follow a similar
  course, etc?
• Not necessarily. Disorders may manifest
  themselves differently in different people. In
  other words, people may have similar symptoms,
  but not entirely. (eg. MDD)
• Also, some disorders can look completely
  different in different people. In other words,
  two people can have the same diagnosis with
  completely different symptoms. (eg. Conduct
  Disorder)

21
Evaluation of the DSM-IV-TR

• Can we use these definitions to distinguish
  between people who do and do not have the
  disorder?
• There is still the criticism that the criteria
  used are based on the clinical judgment of a few
  psychologists in the individual field and not
  representative
• There are still problems differentiating between
  normal and abnormal
• Some criteria are still based on clinical judgment

22
Possible Alternatives

• Categorical vs. Dimensional System
• Categorical
• DSM uses a categorical system of diagnoses that
  assumes disorders are unique and discrete
• Dimensional
• A dimensional model suggests that disorders may
  be points on a continuum (or multiple continua).
  For example, researchers suggest that there may
  be an underlying factor connecting all the
  Internalizing disorders (depression, anxiety,
  etc.) and similarly, all the Externalizing
  disorders (antisocial personality disorder,
  substance use disorders, etc.).