The Diagnosis and Classification of Mental Disorders
When psychologists say that the behavior and thinking of someone with a disorder are “abnormal,” what do they mean? How do psychologists decide when someone’s behavior or thinking has crossed over the line from normal to abnormal? Psychologists use four key criteria. It is important to realize that if a person’s behavior or thinking meets one or more of these criteria, this does not necessarily mean that the person is suffering from a disorder. This will become clear as we discuss each of the criteria, which can be posed as questions.
First, is the behavior or thinking atypical (statistically infrequent)? Of course, not all statistically infrequent behavior or thinking is abnormal. Consider skydiving. That’s an atypical behavior in our society, but it does not mean that a person who skydives has a disorder. Having hallucinations, however, is an atypical behavior that likely does reflect a disorder.
Second, is the behavior or thinking maladaptive? Maladaptive behavior or thinking prevents the person from successfully functioning and adapting to life’s demands. Thus, a disordered person is not able to function in daily life. For example, being afraid to leave one’s home is atypical and maladaptive behavior that would interfere with daily functioning.
Third, is the person or are others distressed by the behavior or thinking? Perhaps a young man is attempting, but failing, to make a living doing odd street stunts. His behavior is atypical and maladaptive (he will soon be penniless), but if he is not disturbed and if his stunts are not disturbing others, then he is not considered disordered.
Fourth, is the behavior or thinking rational? For example, a fear of birds might be so strong that even thinking about them causes great anxiety. The person may realize that this atypical, maladaptive, disturbing fear is not rational but still be unable to suppress the anxiety, and he would therefore be considered disordered.
The Diagnostic and Statistical Manual of Mental Disorders
These criteria help to determine whether a person’s behavior and thinking may be “abnormal,” but how do we know exactly what disorder the person has? The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), published in 2013 by the American Psychiatric Association (APA), is the most widely used diagnostic system for mental disorders, informally referred to as “the bible of mental disorders.” The intent of the DSM-5 is to serve both as a guide and an aid in the accurate diagnosis and treatment of mental disorders. It bases the classification of each disorder upon behavioral and psychological symptoms and defines the diagnostic guidelines for each disorder. The APA published the DSM-5 in print and also plans to publish it as a “living document” that can be updated as new research emerges. These incremental updates will be online and identified with decimals; i.e., DSM-5.1, DSM-5.2, and so on. Previous editions of the DSM were labeled using Roman numerals (e.g., DSM-IV), but the APA changed to Arabic numerals to facilitate the labeling of the versions of the living document.
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The Diagnostic and Statistical Manual of Mental Disorders (DSM) first appeared in 1952, was only 86 pages long, and described about 60 disorders (Cordón, 2005), whereas the DSM-5 is almost 1,000 pages long and describes approximately 400 disorders. Why has the number of disorders in the DSM increased so dramatically, causing the DSM to go from a thin, spiral-bound book to a weighty tome across its five editions? A major reason is that over the last 60 years or so, we have learned a lot about various disorders and how to differentiate them, leading to more and more disorder classifications over successive versions of the DSM. This ability to make better differentiations between disorders has also led to more diagnostic reliability. In fact, the framers of the DSM-5 followed procedures in the development of the manual that would lead to it having greater reliability than previous editions (Regier, Narrow, Kuhl, & Kupfer, 2011). For example, they conducted extensive reviews of research, consulted with numerous clinicians about diagnostic difficulties, and developed new categories and diagnostic criteria for categories that in the past have not been reliable. Thus, a major strength of the DSM-5 is that clinicians using it should be able to make more reliable classifications, which means that clinicians should more frequently agree on a particular diagnosis for a particular patient.
Regardless of this possible gain in reliability, the DSM-5 has been heavily criticized, causing quite a kerfuffle among mental health professionals (e.g., Frances, 2013; Greenberg, 2013). A major criticism is that disorder classification in the DSM-5 is out of control, leading many aspects of normal behavior and ordinary life to fit the criteria for diagnosis of a mental disorder. For example, mental decline that goes a bit beyond normal aging may now be given the new DSM-5 diagnosis of “mild neurocognitive disorder” (giving “senior moments” clinical significance) and children who have recurrent temper outbursts may be given the new DSM-5 diagnosis of “disruptive mood dysregulation disorder.” The DSM-5 has also eliminated the bereavement exclusion for the diagnosis of major depressive disorder. Past versions of the DSM excluded people who had lost a loved one from receiving this diagnosis for the first two months of their bereavement. Thus, many people undergoing a normal grief reaction to the loss of a loved one may now receive a diagnosis of major depressive disorder. Allen Frances, who served as chairman of the DSM-IV task force, argues that the new diagnoses in the DSM-5 turn “everyday anxiety, eccentricity, forgetting, and bad eating habits into mental disorders” (Frances, 2013, pp. xv–xvi). According to Frances, such overdiagnosis will lead not only to a bonanza for the pharmaceutical industry but also to great costs (e.g., unnecessary and possibly harmful drug therapy) for all of the false positive patients (people falsely diagnosed to have a mental disorder). Remember, we discussed the costs of false positives in the context of medical screening tests in Chapter 6. According to critics such as Frances, the DSM-5 with its excessively wide diagnostic net creates an analogous situation in psychiatric diagnosis.
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In spite of its possible flaws, the DSM-5 reflects the current state of our knowledge about mental disorders and serves very important functions, both in clinical practice and in research. It provides a common language and useable classification system for clinicians and clinical researchers to describe, discuss, evaluate, treat, and conduct research on mental disorders. It also serves an important practical purpose—health insurance companies require a DSM-5 disorder classification before paying for therapy. The DSM-5 should be thought of as a work in progress. As our knowledge about mental disorders evolves, so will the DSM.
The DSM-5 has abandoned the multiaxial diagnostic system used in the DSM-IV and moved to a nonaxial assessment system in which a diagnosis requires a clinician to identify the disorder (or disorders) indicated by the person’s symptoms along with dimensional judgments on the severity of the person’s present symptoms and impairment. The DSM-5 provides specific diagnostic criteria, the key clinical features, and background information (such as prevalence rates) for approximately 400 disorders. Some disorders share certain symptoms, so the DSM-5 clusters these disorders into a major category. For example, several disorders that share anxiety as a symptom, such as phobic and panic disorders, are categorized as anxiety disorders. There are 20 major categories in the DSM-5. We will consider some disorders from six of these categories—Anxiety Disorders, Obsessive-Compulsive and Related Disorders, Depressive Disorders, Bipolar and Related Disorders, Schizophrenia Spectrum and other Psychotic Disorders, and Personality Disorders. It is important to remember that the DSM-5 classification system applies to a pattern of symptoms and not to the person, so it refers, for example, to “a person with schizophrenia” and not a “schizophrenic.”
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The Perceptual Bias of Labeling
The downside to classifying a mental disorder, regardless of the system used, is that labels are attached to people, and this biases our perception of these people in terms of the labels. Our perception is no longer objective. Think about the words that are often used to describe people with mental disorders—for example, “crazy,” “lunatic,” “deranged,” “insane,” or “mad.” These words have strong negative connotations. Similarly, diagnostic disorder labels tend to lead to negative perceptions and interpretations of a person’s behavior in terms of the label. The label guides our perception.
There is a famous study that we briefly mentioned in Chapter 1 that demonstrates the perceptual biasing effect of labeling (Rosenhan, 1973). Between 1969 and 1972, David L. Rosenhan, then a psychology professor at Swarthmore College, and seven others (a psychology graduate student, three psychologists, a pediatrician, a housewife, and a painter) went to several different hospitals in five states and tried to gain admission. They each faked a major symptom of schizophrenic disorders, auditory hallucinations (hearing voices). The voice in these cases was saying the words “empty,” “hollow,” and “thud.” Other than this sole symptom, the researchers acted normal and only lied about their true identities. First, they wanted to see whether they would be admitted given this singular symptom. Second, they wanted to see what would happen after they were admitted if they acted normal and said that they no longer heard the voices and that they were feeling normal again. Here’s what happened. In brief, all of the pseudopatients (fake patients) were admitted with a diagnosis of schizophrenia and were stuck in psychiatric wards for between 8 and 52 days. Their subsequent normal behavior was misinterpreted in terms of their diagnoses. For example, one person’s excessive note taking was interpreted as a function of his illness when, in fact, he was just trying to take notes to document the study. What kind of treatment did they receive? For the most part, they were given antipsychotic medications—an estimated 2,100 pills, though only two were taken. The pseudopatients just pretended to take the pills, pocketed them, and flushed them down the toilet. Ironically, some of the true patients realized that the pseudopatients were not true patients; but the staff, guided by the diagnostic labels, did not. Even when the pseudopatients were released (which took a while for some of them), they carried the label “schizophrenia in remission.”
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There was a secondary study included that is not often mentioned, but it is interesting because it provides a clear demonstration of perceptual bias. The staff of a hospital, which was aware of the primary study, was falsely informed that one or more pseudopatients would attempt to gain admission to the hospital over the next three months. Rosenhan did not send any pseudopatients, but of the 193 real patients who came to the hospital for admittance with symptoms of a disorder, 83 (43%) were either suspected or confidently judged to be a pseudopatient by at least one psychiatrist or staff member. Remember from Chapter 3, seeing is believing, but it isn’t always believing correctly.
Perceptual biasing is further complicated by the misrepresentation of disordered people on television and in other media. They are often depicted as violent and dangerous to others when the vast majority of people with disorders are not a threat to anyone except maybe themselves (Applebaum, 2004; Lilienfeld, Lynn, Ruscio, & Beyerstein, 2010; Teplin, 1985). Most people with mental disorders are experiencing a troubled period in their lives and are finding it difficult to adjust. Remember to distinguish between the person and the label. We need labels in order to know how to treat people with problems and to conduct research on these problems, but there is much more to a person than a label.
Now that we have a general understanding of the diagnostic classification system and its strengths and weaknesses, we will consider some of the mental disorders (labels) that are identified in the DSM-5.
Section Summary
In this section, we first discussed the criteria for classifying behavior and thinking as abnormal and then how mental disorders are diagnosed and classified. The criteria for abnormality are that one’s behavior and thinking are atypical, maladaptive, cause distress, and are not rational. The most widely used diagnostic system is the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5). The DSM-5 bases classification upon behavioral and psychological symptoms and provides diagnostic guidelines for about 400 disorders. Because some disorders share certain symptoms, the DSM-5 clusters the disorders into 20 major categories, such as Anxiety Disorders and Depressive Disorders. The DSM-5 should be viewed as a work in progress and will also be published as a living document, with future versions such as DSM-5.1, DSM-5.2, etc. as new research findings emerge.
A major strength of the DSM-5 is that it was developed to be more reliable than previous editions. Regardless of its reliability, the DSM-5 has been criticized for casting too wide of a diagnostic net, possibly leading to normal behavior being classified as abnormal. In spite of its possible flaws, the DSM-5 reflects the current state of our knowledge about mental disorders and serves very important functions, both in clinical practice and in research. It provides a common language and useable classification system for clinicians and clinical researchers to describe, discuss, evaluate, treat, and conduct research on mental disorders. It also serves an important practical purpose—health insurance companies require a DSM-5 disorder classification before paying for therapy.
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The downside to disorder classification is that labels are attached to people, thereby biasing our perception of these people in terms of their labels. Such perceptual biasing is further complicated by the misrepresentation of people with disorders by the media as violent and dangerous when most are not a threat to anyone except possibly themselves. Although labeling does lead to such perceptual bias, we need to use labels to both diagnose and treat people with disorders.
ConceptCheck | 1
Explain what the DSM-5 is.The DSM-5 is the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, published by the American Psychiatric Association. It is the most widely used diagnostic system for classifying mental disorders. Basing its classification upon behavioral and psychological symptoms, it provides reliable diagnostic guidelines for approximately 400 disorders, grouped into major categories that share particular symptoms.
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Explain the negative effect of attaching labels to disorders and why we need labels even though we know they have such effects.
Labels attached to people bias our perception of these people in terms of their labels. Labels for mental disorders are especially problematic, because they tend to lead to negative perceptions and interpretations of a person’s behavior in terms of the label. In brief, labels guide our perception. Therefore, it is important to realize that there is much more to a person than a label. However, we need labels in order to know how to treat people with disorders and to conduct research on these disorders. This is why labels are necessary.