Clinicians use the information from interviews, tests, and observations to construct an integrated picture of the factors that are causing and maintaining a client’s disturbance, a construction sometimes known as a clinical picture (Goldfinger & Pomerantz, 2014; Kellerman & Burry, 2007). Clinical pictures also may be influenced to a degree by the clinician’s theoretical orientation (Garb, 2010, 2006). The psychologist who worked with Franco held a cognitive-behavioral view of abnormality and so produced a picture that emphasized modeling and reinforcement principles and Franco’s expectations, assumptions, and interpretations:

With the assessment data and clinical picture in hand, clinicians are ready to make a diagnosis (from the Greek word for “a discrimination”)—that is, a determination that a person’s psychological problems constitute a particular disorder. When clinicians decide, through diagnosis, that a client’s pattern of dysfunction reflects a particular disorder, they are saying that the pattern is basically the same as one that has been displayed by many other people, has been investigated in a variety of studies, and perhaps has responded to particular forms of treatment. They can then apply what is generally known about the disorder to the particular individual they are trying to help. They can, for example, better predict the future course of the person’s problem and the treatments that are likely to be helpful.

The principle behind diagnosis is straightforward. When certain symptoms occur together regularly—a cluster of symptoms is called a syndrome—and follow a particular course, clinicians agree that those symptoms make up a particular mental disorder (see Table 4-3). If people display this particular pattern of symptoms, diagnosticians assign them to that diagnostic category. A list of such categories, or disorders, with descriptions of the symptoms and guidelines for assigning individuals to the categories, is known as a classification system.

In 1883, Emil Kraepelin developed the first modern classification system for abnormal behavior (see Chapter 1). His categories formed the foundation for the Diagnostic and Statistical Manual of Mental Disorders (DSM), the classification system currently written by the American Psychiatric Association (APA, 2013). The DSM is the most widely used classification system in North America. Most other countries rely primarily on a system called the International Classification of Diseases (ICD), developed by the World Health Organization, which lists both medical and psychological disorders. Although there are a number of differences between the disorders listed in the DSM and ICD and in their descriptions of criteria for various disorders (the DSM’s descriptions are more detailed), the federal government has required that by the end of 2014, the numerical codes used by the DSM for all disorders must match those used by the ICD—a matching that is expected to lead to more uniformity and accuracy when clinicians fill out insurance reimbursement forms.

The content of the DSM has been changed significantly over time. The current edition, called DSM-5, was published in 2013. It features a number of changes from the previous edition, DSM-IV-TR, and the editions prior to that. It may seem like the DSM-5 shift from using Roman numerals to Arabic numerals for its title is but a cosmetic one, much like the “Super Bowl 50” shift from Roman to Arabic numerals that is scheduled to take place in 2016. In fact, however, the DSM is changing to Arabic numerals in anticipation of the periodic DSM updates that will be made online over the coming years—updates that can now be distinguished as DSM-5.1, DSM-5.2, and so on.

DSM-5 lists more than 500 mental disorders (see Figure 4-3). Each entry describes the criteria for diagnosing the disorder and the key clinical features of the disorder. The system also describes features that are often but not always related to the disorder. The classification system is further accompanied by background information such as research findings; age, culture, or gender trends (see PsychWatch below); and each disorder’s prevalence, risk, course, complications, predisposing factors, and family patterns.

DSM-5 requires clinicians to provide both categorical and dimensional information as part of a proper diagnosis. Categorical information refers to the name of the distinct category (disorder) indicated by the client’s symptoms. Dimensional information is a rating of how severe a client’s symptoms are and how dysfunctional the client is across various dimensions of personality and behavior.

Categorical InformationFirst, the clinician must decide whether the person is displaying one of the hundreds of psychological disorders listed in the manual. Some of the most frequently diagnosed disorders are the anxiety disorders and depressive disorders.

ANXIETY DISORDERSPeople with anxiety disorders may experience general feelings of anxiety and worry (generalized anxiety disorder); fears of specific situations, objects, or activities (phobias); anxiety about social situations (social anxiety disorder); repeated outbreaks of panic (panic disorder); or anxiety about being separated from one’s parents or other key individuals (separation anxiety disorder).

DEPRESSIVE DISORDERSPeople with depressive disorders may experience an episode of extreme sadness and related symptoms (major depressive disorder), persistent and chronic sadness (persistent depressive disorder), or severe premenstrual sadness and related symptoms (premenstrual dysphoric disorder).

Although people may receive just one diagnosis from the DSM-5 list, they often receive more than one. Franco would likely receive a diagnosis of major depressive disorder. In addition, let’s suppose the clinician judged that Franco’s worries about his teachers’ opinions of him and his later concerns that supervisors at work would discover his inadequate skills were really but two examples of a much broader, persistent pattern of excessive worry, concern, and avoidance. He might then receive an additional diagnosis of generalized anxiety disorder. Alternatively, if Franco’s anxiety symptoms did not rise to the level of generalized anxiety disorder, his diagnosis of major depressive disorder might simply specify that he is experiencing some features of anxiety (major depressive disorder with anxious distress).

Dimensional InformationIn addition to deciding what disorder a client is displaying, diagnosticians assess the current severity of the client’s disorder—that is, how much the symptoms impair the client. For each disorder, the framers of DSM-5 have suggested various rating scales that may prove useful for evaluating the severity of the particular disorder (APA, 2013). In cases of major depressive disorder, for example, two scales are suggested by DSM-5: the Cross-Cutting Symptom Measure and the Emotional Distress—Depression Scale. The former scale indicates the current frequency of various problematic feelings and behaviors (for example, “I do not know who I really am or what I want out of life”) and the latter indicates the frequency of various depression-specific feelings and behaviors (for example, “I feel worthless”). Using scores from these scales, the diagnostician then rates the client’s depression as “mild,” moderate,” or “severe.” Based on his clinical interview, tests, and observations, Franco might warrant a rating of moderate depression from his therapist. DSM-5 is the first edition of the DSM to consistently seek both categorical and dimensional information as equally important parts of the diagnosis, rather than categorical information alone.

Additional InformationClinicians also may include other useful information when making a diagnosis. They may, for example, indicate special psychosocial problems the client has. Franco’s recent breakup with his girlfriend might be noted as relationship distress. Altogether, Franco might receive the following diagnosis:

Diagnosis: Major depressive disorder with anxious distress

Severity: Moderate

Additional information: Relationship distress

A classification system, like an assessment method, is judged by its reliability and validity. Here reliability means that different clinicians are likely to agree on the diagnosis when they use the system to diagnose the same client. Early versions of the DSM were at best moderately reliable (Regier et al., 2011; Malik & Beutler, 2002). In the early 1960s, for example, four clinicians, each relying on DSM-I, the first edition of the DSM, independently interviewed 153 patients (Beck et al., 1962). Only 54 percent of their diagnoses were in agreement. Because all four clinicians were experienced diagnosticians, their failure to agree suggested deficiencies in the classification system.

The framers of DSM-5 followed certain procedures in their development of the new manual to help ensure that DSM-5 would have greater reliability than the previous DSMs (APA, 2013; Hyman, 2011). For example, they conducted extensive reviews of research to pinpoint which categories in past DSMs had been too vague and unreliable. In addition, they gathered input from a wide range of experienced clinicians and researchers. They then developed a number of new diagnostic criteria and categories, expecting that the new criteria and categories were in fact reliable. Despite such efforts, some critics continue to have concerns about the procedures used in the development of DSM-5 (Brown, Holland, & Keel, 2014; Freedman et al., 2013; Frances, 2013). They worry, for example, that the framers failed to run a sufficient number of their own studies—in particular, field studies that test the merits of the new criteria and categories. In turn, the critics fear that DSM-5 may have retained several of the reliability problems that were on display in the past DSMs. It may be, for example, that, as DSM-5 continues to be used over the coming years, many clinicians will have difficulty distinguishing one kind of DSM-5 anxiety disorder from another. The disorder of a particular client may be classified as generalized anxiety disorder by one clinician, agoraphobia (fear of traveling outside of one’s home) by another, and social anxiety disorder (fear of social situations) by yet another. Studies on such issues are now under way and should soon reveal whether these concerns are warranted.

The validity of a classification system is the accuracy of the information that its diagnostic categories provide. Categories are of most use to clinicians when they demonstrate predictive validity—that is, when they help predict future symptoms or events. A common symptom of major depressive disorder is either insomnia or excessive sleep. When clinicians give Franco a diagnosis of major depressive disorder, they expect that he may eventually develop sleep problems even if none are present now. In addition, they expect him to respond to treatments that are effective for other depressed persons. The more often such predictions are accurate, the greater a category’s predictive validity.

DSM-5’s framers tried to also ensure the validity of this new edition by conducting extensive reviews of research and consulting with numerous clinical advisors. As a result, its criteria and categories may have stronger validity than those of the earlier versions of the DSM. But, again, many clinical theorists worry that at least some of the criteria and categories in DSM-5 are based on weak research and that others may reflect gender or racial bias (Koukopoulos & Sani, 2014; Rhebergen & Graham, 2014; Frances, 2013; Freedman et al., 2013). Once again, current studies on issues of this kind should soon clarify the merits of such concerns.

Actually, one important organization, the National Institute of Mental Health (NIMH), has already concluded that the validity of DSM-5 is sorely lacking and is acting accordingly (Insel & Lieberman, 2013; Lane, 2013). The world’s largest funding agency for mental health research, NIMH has announced that it will no longer give financial support to clinical studies that rely exclusively on DSM-5 criteria. And, more generally, the agency continues to develop its own classification tool, called the Research Domain Criteria (RDoC), which it expects to eventually be the primary such tool used by researchers. While the NIMH announcement is certainly a blow to the prestige of DSM-5, it is worth noting that the RDoC is itself receiving considerable criticism from many clinical theorists. They believe that the final version of this new tool, which is based on the premise that mental disorders are best viewed and studied as biological disorders, will minimize environmental and psychological factors in its classifications, while focusing excessively on genetics, brain scans, cognitive neuroscience, and other such areas of study (Lane, 2013).

The effort to produce DSM-5 took more than a decade. After years of preliminary work, a DSM-5 task force and numerous work groups were formed in 2006; with the goal of developing a DSM that addressed the limitations of previous DSM editions. As noted earlier, the task force and work groups conducted scientific reviews and gathered input from a wide range of clinical advisors to help develop a DSM that would reflect current insights, research findings, and clinical concerns (APA, 2013).

Between 2010 and 2012, the task force released several drafts of DSM-5 online and asked clinical researchers and practitioners to offer their suggestions. Given the outreach of the Internet, the response from the clinical community was enormous—beyond anything the previous DSM task forces had received. And not surprisingly, given the diversity of orientations in the clinical field today, the response was wide-ranging—including an onslaught of criticism from many quarters. The DSM-5 task force took the online feedback into consideration and completed the new edition of the classification system. Finally, in May 2013 DSM-5, the new diagnostic and classification system, was published. The categories and criteria of DSM-5 are featured throughout this textbook (APA, 2013).

Some of the key changes in DSM-5 are the following:

Even with trustworthy assessment data and reliable and valid classification categories, clinicians will sometimes arrive at a wrong conclusion (Faust & Ahern, 2012; Trull & Prinstein, 2012). Like all human beings, they are flawed information processors. Studies show that they are overly influenced by information gathered early in the assessment process (Dawes, Faust, & Meehl, 2002; Meehl, 1996, 1960). They sometimes pay too much attention to certain sources of information, such as a parent’s report about a child, and too little to others, such as the child’s point of view (McCoy, 1976). Finally, their judgments can be distorted by any number of personal biases—gender, age, race, and socioeconomic status, to name just a few (Trull & Prinstein, 2012; Vasquez, 2007). Given the limitations of assessment tools, assessors, and classification systems, it is small wonder that studies sometimes uncover shocking errors in diagnosis, especially in hospitals (Mitchell, 2010; Vickrey, Samuels, & Ropper, 2010).

In a classic study, for example, a clinical team was asked to reevaluate the records of 131 patients at a mental hospital in New York, conduct interviews with many of these persons, and arrive at a diagnosis for each one (Lipton & Simon, 1985). The researchers then compared the team’s diagnoses with the original diagnoses for which the patients were hospitalized. Although 89 of the patients had originally received a diagnosis of schizophrenia, only 16 received it upon reevaluation. And whereas 15 patients originally had been given a diagnosis of a mood disorder, 50 received it now. It is obviously important for clinicians to be aware that such huge disagreements can occur.

Beyond the potential for misdiagnosis, the very act of classifying people can lead to unintended results. As you read in Chapter 3, for example, many family-social theorists believe that diagnostic labels can become self-fulfilling prophecies. When people are diagnosed as mentally disturbed, they may be perceived and reacted to correspondingly. If others expect them to take on a sick role, they may begin to consider themselves sick as well and act that way. Furthermore, our society attaches a stigma to abnormality (Hansson et al., 2014; Bell et al., 2011). People labeled mentally ill may find it difficult to get a job, especially a position of responsibility, or to be welcomed into social relationships. Once a label has been applied, it may stick for a long time.

Because of these problems, some clinicians would like to do away with diagnoses. Others disagree. They believe we must simply work to increase what is known about psychological disorders and improve diagnostic techniques. They hold that classification and diagnosis are critical to understanding and treating people in distress.