CHAPTER 5:
Diagnosis and Classification of Psychological
Problems
Psychopathologist
 a scientist who studies the causes of
mental disorders as well as the factors
that influence the development of
mental disorders
Abnormal Behavior
 abnormal behavior does not necessarily
indicate mental illness.
 One can exhibit a wide variety of
abnormal behaviors (as judged by any
definition) and yet not receive a mental
disorder diagnosis.
Statistical infrequency or violation of social
norms
 when a person’s behavior becomes
patently deviant, outrageous, or
otherwise nonconforming, then he or she
is more likely to be categorized as
“abnormal.”
 Behavior depart considerably from the
mean
 aspect of deviance from the norm is very
clear
 it can be described statistically and with
numbers
 do not conform to the norms typical of
the culture
Advantages of This Definition.
Cutoff Points
 The statistical infrequency approach is
appealing because it establishes cutoff
points that are quantitative in nature
 sample of test-takers, and scores at or
beyond the cutoff are considered
“clinically significant
Intuitive Appeal
 The struggle to define exactly what
abnormal behavior is does not tend to
bother us
 we believe that we know it when we see
it.
Problems with This Definition
 we should resist the reflexive tendency
to categorize every nonconformist
behavior as evidence of mental health
problem
Choice of Cutoff Points
 Conformity-oriented definitions are
limited by the difficulty of establishing
agreed-upon cutoff points
The Number of Deviations
 nonconformity standards are the number
of behaviors that one must evidence to
earn the label “deviant.”
Cultural and Developmental Relativity
 what is deviant for one group is not
necessarily so for another
 the notion of cultural relativity is
important
 variability may contribute to
considerable diagnostic unreliability
because even clinicians’ judgments may
be relative to those of the group or
groups to which they belong.
 some behaviors that may seem
appropriate at one developmental stage
may appear inappropriate at another
developmental stage
 Cultures can be reduced to subcultures
and subcultures to minicultures
 excessive conformity has itself
sometimes been the basis for judging
persons abnormal
The experience of subjective distress
 perceptions of the affected individual.
 the basic data are not observable
deviations of behavior, but the
subjective feelings and sense of well-
being of the individual.
Advantages of This Definition
 many methods of clinical assessment
(e.g., self-report inventories, clinical
interviews) assume that the respondent
is aware of his or her internal state and
 will respond to inquiries about personal
distress in an honest manner
Problems with This Definition
 The judgment will depend on one’s
criteria or values.
 labeling someone maladjusted is not
very meaningful unless the basis for the
judgment is specified and the behavioral
manifestations are stated
 Not everyone whom we consider to be
“disordered” reports subjective distress.
 using phenomenological reports is
subject to limitations.
Disability, dysfunction, or impairment
 For behavior to be considered abnormal,
it must create some degree of social
(interpersonal) or occupational (or
educational) problems for the individual.
Advantages of This Definition
 Problems in both the social and
occupational sphere often prompt
individuals to seek out treatment
 individuals come to realize the extent of
their emotional problems when these
problems affect their family or social
relationships as well as significantly
affect their performance at either work
or school.
Problems with This Definition
 achieving a reliable consensus about the
nature of an individual’s social
relationships and contributions as a
worker or student may be difficult
Mental Illness
 mental illness refers to a large class of
frequently observed syndromes that are
comprised of certain abnormal behaviors
or features.
 significant behavioral or psychological
syndrome or pattern that occurs in an
individual and that is associated with
present distress (e.g., a painful
symptom) or disability (i.e., impairment
in one or more important areas of
functioning) or with a significantly
increased risk of suffering, death, pain,
disability, or an important loss of
freedom
 it must currently be considered a
manifestation of a behavioral,
psychological, or biological dysfunction
in the individual
Important definition
 syndrome cluster of abnormal
behaviors) must be associated with
distress, disability, or increased risk of
problems
 is considered to represent a dysfunction
within an individual
 not all deviant behaviors or conflicts
with society are signs of mental disorder
Diagnostic and Statistical Manual of Mental
Disorder
 The prevailing diagnostic guide for
mental health professionals as they
perform assessments, conduct therapy,
and design and execute research studies.
 DSM-IV-TR, is the official diagnostic
system for mental disorders in the
United States.
 DSM-IV-TR definition of mental
disorder incorporates the three
definitions of abnormal behavior
 DSM-IV-TR definition is more
comprehensive than any one of the three
individual definitions of abnormal
behavior
 DSM-IV-TR definition is more
restrictive because it focuses on
syndromes, or clusters of abnormal
behaviors, that are associated with
distress, disability, or an increased risk
for problems.
International Classification of Diseases (ICD)
 Basis for health recording and statistics
on disease in primary, secondary and
tertiary care, as well as on cause of
death certificates.
The Importance of Diagnosis
 Diagnosis is a type of expert-level
categorization
  Categorization is essential to our
survival because it allows us to make
important distinctions
 The diagnosis of mental disorders is an
expert level of categorization used by
mental health professionals that enables
us to make important distinctions
Major advantages of diagnosis
 primary function of diagnosis is
communication.
 Diagnosis can be thought of as “verbal
shorthand” for representing features of a
particular mental disorder.
 Diagnostic systems for mental disorders
are especially useful for communication
because these classificatory systems are
largely descriptive
 The use of diagnoses enables and
promotes empirical research in
psychopathology
 the way diagnostic constructs are
defined and described will stimulate
research on the disorders’ individual
criteria, on alternative criteria sets, and
on the comorbidity (co-occurrence)
between disorders
 research into the etiology, or causes, of
abnormal behavior would be almost
impossible to conduct without a
standardized diagnostic system
 they may suggest which mode of
treatment is most likely to be effective
 this is a general goal of a classification
system for mental disorders
Early Classification Systems
2600 B.C
 earliest reference to depressive
syndrome appeared
Paris (1889)
 Congress of Mental Science adopted a
single classification system
World Health Organization (1948)
 International Statistical Classification of
Diseases, Injuries, and Causes of Death,
which included a classification of
abnormal behavior
American Psychiatric Association (1952)
 published its own classification system
in the Diagnostic and Statistical Manual,
and this manual contained a glossary
describing each of the diagnostic
categories that were included
 embodiments of Emil Kraepelin’s
efforts in the late 19th century
DSM-I (1952)
 First edition
 2 main sections: Disorders with
established organic brain disease and
Disorders without evidence of organic
brain findings.
DSM-II (1968)
 Increased compatibility with WHO’s
ICD
 Addition of child/adolescent section
 3 categories: Psychoses, Neuroses, and
Character
DSM-III (1980) / DSMIII-R (1987)
 Relied on empirical data;
Used specific diagnostic criteria to
define disorders;
A theoretical approach; and
Introduced the multiaxial assessment
system.
 a descriptive approach to diagnosis that
attempted to be neutral with regard to
theories of etiology
 The 5 Axes:
 AXIS I: Clinical Disorders
 AXIS II: Personality Disorders and
Mental Retardation
 AXIS III: General Medical Conditions
 AXIS IV: Psychosocial and
Environmental Problems
 AXIS V: Global Assessment of
Functioning Scale
DSM-IV (1994) / DSM-IV-TR (2000)
  Prompted by the upcoming release of
new
international criteria (ICD-10) in 1993
 Had few significant changes from the
previous
criteria
 Systematic addition of “clinically
significant distress or impairment
“across the diagnostic criteria
 More detail on associated features of
disorders and updated research
literature(DSM-IV-TR).
DSM-5(2013)
 Revised Disorders in DSM-5:
The “bereavement exclusion” for major
depressive episode was dropped.
 The DSM-IV diagnoses of autistic
disorder, Asperger’s disorder, and
related developmental disorders were
combined into a single DSM-5
diagnosis: Autism Spectrum Disorder.
Mental retardation was renamed
Intellectual
Development Disorder.
 Learning disabilities in reading, math,
and writing were combined into a single
diagnosis with a new name: Specific
Learning Disorder.
 Obsessive-compulsive disorder was
placed into its own new category:
Obsessive-Compulsive and Related
Disorders.
 The category of Mood Disorders was
split into two: Depressive Disorders (in
which mood is singularly sad) and
Bipolar and Related Disorders.
 The category of Mood Disorders was
split into two: Depressive Disorders (in
which mood is singularly
DSM-5-TR (2022)
 Revised text for almost all disorders
with updated sections on associated
features, prevalence, development and
course, risk and prognostic factors,
culture, diagnostic markers, suicide, and
differential diagnosis;
Addition of new diagnosis: Prolonged
Grief Disorder
 Addition of the following: Unspecified
Mood Disorder; Suicidal and Non-
Suicidal Self-injurious Behavior
(symptom codes)
 Modifications of the diagnostic criteria
for more than 70 disorders;
Emphasis on gender-inclusive language;
and
Considerations of the impact of racism
and
discrimination on mental disorders.
DC 0–3(1994)
 Diagnostic Classification System
 To help classify psychopathology
among very young children, a similar
manual has been developed for children
aged 0–3 years
DC 0–3R (2005)
 The multiaxial assessment also is used
GENERAL ISSUES IN CLASSIFICATION
Categories Approach
 Classical or Pure
The basic view that an individual “has
“or “does not have “the disorder—that
is, the individual can be placed
definitively in the “yes” or “no”
category regarding a particular form of
psychopathology.
There is only one set of defining criteria,
which everybody in the category has to
meet
 the patient is placed in a category
 abnormal behavior: are endpoints of a
continuous dimension
 The difference between so-called normal
behavior and psychotic behavior, for
example, is one of degree rather than
kind
  the categorical model may misrepresent
the true nature of the diagnostic
construct
 there may be relatively few diagnostic
constructs that are truly categorical in
nature.
Bases of Categorization
 patients are classified almost solely on
the basis of their current behavior or
presenting symptoms
 In other cases, the judgment is made
almost entirely on the basis of history
 A major implication is that membership
in any one diagnostic category is likely
to be heterogeneous because there are
multiple bases for a diagnosis.
Dimensional Approach
 We note the variety of cognitions,
moods, and
behaviors with which the patient
presents and
quantify them on a scale.
The issue isn’t the presence or absence
of a disorder; instead, the issue is where
on a continuum a client’s symptoms fall.
 it is only when our thinking patterns,
emotions, and behaviors cause great
distress or problems that we consider
these indicative of a disorder, in the
diagnostic sense
 this dimensional perspective highlights
that our ability to react adaptively is a
matter of degree.
Pragmatics of Classification
 Identifies certain essential
characteristics of an entity so that you
(and others) can classify it, but it also
allows certain nonessential variations
that do not necessarily change the
classification.
A certain number of prototypical criteria
and only some of an additional number
of criteria is adequate
 Psychiatric classification has always
been accompanied by a certain degree of
appeal to medical authority
 that classification systems such as the
DSM are crafted by committees. The
members of such committees represent
varying scientific, theoretical,
professional, and even economic
constituencies.
Reliability
 refers to the consistency of diagnostic
judgments across raters
 much of the unreliability problem
seemed to lie with the diagnosticians
and/or the diagnostic system itself
 diagnostic unreliability is the rule and
not the exception.
 structured diagnostic interviews:
address these concerns about reliability
Validity
 Reliability will directly affect the
validity of a diagnostic system
establishing the diagnostic validity of a
syndrome:
 clinical description: description
characteristic features beyond the
disorder’s symptoms
 laboratory studies: to identify
meaningful correlates of the diagnosis
 delimitation from other disorders: to
ensure some degree of homogeneity
among diagnostic members
 follow-up studies: to assess the test–
retest reliability of a diagnosis
 family studies: to demonstrate that the
proposed disorder tends to run in
families
Bias
 The two areas of potential bias that have
received the most attention are sex bias
and racial bias
 DSM system as a male-centered device
that overestimates pathology in females
 one’s culture can affect many factors
related to the diagnosis and treatment of
mental illness
  culture can influence belief systems that
may lead to the experience of stress and
then to symptoms of mental disorder
 The content or characteristics of
symptoms of mental disorder may also
vary by culture
 it is important for clinicians to consider
cultural influences when diagnosing and
treating individuals for mental illness
 Stigma is also a major reason people do
not seek treatment for mental distress
Major Models of Psychopathology
Biological
 Processes in central nervous system
(CNS) have gone awry
 Schizophrenia is caused by an excess of
dopaminergic activity.
 Developmental Psychopathology
Maladjustment arises from a distortion
in the path or trajectory in healthy
adaptation; maladjustment is due to
interactions between the individual and
their environment
 Depression is caused by interpersonal
stressors that make it hard to learn
appropriate coping skills, and depression
cyclically leads to later additional
interpersonal stressors
Psychodynamic
 Intrapsychic Conflict
 Specific phobia is due to the
displacement of an intrapsychic conflict
onto an external object that can then be
avoided.
Learning
 Learned the same way normal behavior
is learned
 Specific phobia is learned via classical
conditioning.
Cognitive
 Due to maladaptive cognitions
 Depression results from negative views
about oneself, the world, and the future.
Humanistic
 Relative neglect of one’s own self-view
and overreliance on the appraisals of
others when the two are incongruous
 Generalized anxiety disorder reflects
this overreliance and incongruity.
Diathesis-Stress Model
 incorporate biological, psychological,
and environmental factors
 diathesis refers to a vulnerability or
predisposition to possibly develop the
disorder in question
 A diathesis can be biological (e.g., a
genetic predisposition, a deficit or
excess in neurotransmitter functioning)
or psychological (e.g., maladaptive
cognitive schema, maladaptive
personality style)
 the combination of a predisposition and
stress (or stressors) may produce
psychological problems.
 What is required in addition to a
diathesis is sufficient stress
 It is the interplay between the
predisposition and stress that will
determine whether a disorder develops
 stress can be environmental (e.g., victim
of an assault), biological (e.g., poor
nutrition), interpersonal (e.g.,
acrimonious marriage), or even
psychological (e.g., toxic family
environment).
 a diathesis or predisposition influence
the perception of stress
 one’s predisposition is likely to
influence a person’s own life course and
choice of experiences
 Our experiences are influenced by a
number of preferences and decisions we
make
 a diathesis will at least partially
determine the range and varieties of life
events that we experience, some of
which may be perceived as stressful.
 This model helps us begin to understand
why two people exposed to the same
adverse conditions and levels of stress
may have different outcomes.