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

Mushroom Not 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 (18 th C)

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 Genderrelated 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 à Diagnosis Assessment à Formulation

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

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, selfregulation, 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 Male Female Pregnant Not Pregnant

Classification Continuous? Are the disorders on a continuum? Nondepressed Depressed

Discrete Categories? Depressed Not Depressed Normal Abnormal