Mental health articles

OF mental health care and mentally ill

Abnormal Behavior in Psychology

Psychiatric Approaches

The American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM-III, DSM-III-R, and IV). The first two editions of the American Psychiatric Association’s  classification scheme were uniformly unsatisfactory and subject to valid theoretical and practical criticism. Begelman  summarized a number of published articles and derived a fairly comprehensive list of criticisms. In response to these criticisms and concurrent with resurgent emphasis on the medical foundations of psychiatry, a third edition of the Diagnostic and Statistical Manual was published in 1980. DSM-III had a more complex system than previous editions, encompassing twice as many separate diagnostic descriptions as DSM-II. It was developed to reflect the current state of knowledge regarding mental disorders by

(1) allowing clear and brief professional communication to facilitate inquiry, (2) providing a guide to current differentiated treatments, (3) providing information concerning likely outcomes with and without treatment, (4) reflecting the current level of knowledge of etiology and pathophysiology, and (5) meeting the needs of practitioners and administrators in a wide variety of settings. DSM-III corrected many problems inherent in DSM-II. First, DSM-III was not heavily influenced by any given theoretical position except the assumption that aberrant behavior is an illness. Second, it adopted a more operational language and required that specific criteria be met before an individual was diagnosed. This latter aspect led to more homogeneous categories and helped reduce disjunctive categories. The attempt to develop an empirical classification was continued with the development of the DSM IV. In essence, thirteen workgroups, each chaired by a member of the task force whose members were appointed by the Board of Trustees of the American Psychiatric Association, reviewed the data on various subgroups of disorders to modify the criteria of DSM III and III-R, if necessary, or to develop new criteria for each type of disorder. These empirical reviews were intended to resolve issues of criteria and clinical controversies by a comprehensive overview of the relevant research by a scholar who was, hopefully, neutral on these issues. We think it is fair to say that this produced some good and useful review but did not resolve many of the controversies because there are many ‘‘gaps’’ in the literature and because of the more fundamental problem of the assumptions made by this classification model, as vociferously and frequently discussed by Robert Carson.

Nevertheless, the culmination of these literature reviews and data reanalyses was the DSM-IV sourcebooks. These books presented the major diagnostic issues, as well as options for dealing with them, and encouraged critical and constructive comments. The next stage was to perform focused field trials to determine the reliability/validity of the revised criteria and to address some of the issues raised by the literature reviews. A DSM-IV draft criteria was then published to invite reviews and comments which led to the publication of the DSM-IV. It has to be admitted that a great deal of work and thought went into the final version. Although certainly not perfect nor acceptable to some, this classification system is much better than our earlier efforts. The major innovation introduced in DSM-III, III-R, and IV’s psychiatric diagnostic classification is the use of five dimensions or axes, which are designed for planning treatment and predicting outcome, as well as in categorizing and classifying. Some minor modifications in the multiaxial system were implemented in the 1987 revision (DSM-III-R) and in DSM-IV. These axes will be described as covered in the DSM-IV. Axis I: Clinical Disorders and Other Conditions That May Be a Focus of Clinical Attention.This axis is used to designate behavioral patterns associated with such abnormal states as schizophrenia, bipolar affective disorder, or dysthymic disorder. It covers all of the psychological disorders except the personality disorders and mental retardation. An individual may have more than one of these disorders and all should be reported. The principal reason for the visit should be labeled as the ‘‘Principal Diagnosis.’’ Axis II: Personality Disorders and Mental Retardation.This axis was used in the DSM-III to designate specific developmental disorders, such as learning disabilities in children and adolescents, as well as personality disorders in adults. In DSM-III-R, mental retardation was removed from Axis I to Axis II at the suggestion of Kendell and others who felt that the changes to Axis II would better distinguish ‘‘lifelong and stable handicaps’’ and restrict them to a single axis. In the DSM-IV, developmental disorders have been placed on Axis I, and Axis II is reserved for personality disorders and mental retardation. This change was an improvement. A major difficulty with Axis II is low reliability and much overlap or comorbidity among the categories. Recently, two very innovative studies of the classification of personality disorders were conducted by Westen and Shedler. They noted that the assessment of personality disorders has relied almost exclusively on self-report inventories and assessed DSM-IV categories and criteria, which limits their utility in making meaningful revisions of these criteria. They devised an assessment tool, the Shedler–Westen Assessment Procedure or the SWAP-200, where the clinicians rated their patients on 200 items. These items included descriptions such as ‘‘has an exaggerated sense of self-importance,’’ ‘‘seeks to be the center of attention,’’ ‘‘tends to feel helpless, powerless, or at the mercy of forces outside his/her control,’’ and a number of similar items from a variety of clinical sources. A Q-sort technique was used in which the statements (i.e., items) were printed on separate index cards. The clinician then sorted the cards into eight categories where the first category (assigned a value of ‘‘0’’) contained statements judged irrelevant or inapplicable to the patient and the last category (assigned a value of ‘‘7’’) contained statements that were highly relevant or applicable to the individual. The Q-sort technique required that the clinician assign a specific number of statements to each category. For example, with the Swap-200, the clinicians must place eight items into category 7 (i.e., the most relevant items), ten items into category 6 (i.e., the next most relevant items), and so on until all items have been exhausted and assigned to specific categories.

Clinicians then rated a hypothetical prototypical patient who exhibited a histrionic personality disorder, which allowed the development of a diagnostic prototype. Then they rated actual patients with specific personality disorders. A composite description of the patients could then be developed. The correlation between the composite description and the diagnostic prototype yielded a personality disorder score (ten disorders currently in Axis II, four disorders in the appendix or previous versions of the DSM, and a prototype of a healthy, functioning person). The personality score obtained indicated how closely the patient ‘‘matched’’ the diagnostic protocol for each personality disorder. Their results show high divergence and discrimination in a variety of criteria. Using this methodology, Westen and Shedler developed an empirical classification system of personality disorder taxonomy. Their analysis found eleven naturally occurring diagnostic categories, some of which resemble current DSMIV personality categories, whereas others do not. In some cases, the DSM-IV categories place dissimilar cases in the same categories and in other cases made diagnostic distinctions when none actually existed. The empirically derived system is more faithful to the clinical data and eliminated much of the comorbidity in their categories. Thus, the system proposed by Westen and Shedler eliminates much of the difficulty resulting from comorbidity that plagues the current classification system for personality disorders proposed by the DSM-IV.

These are the categories that resulted from the classification system proposed by Westen and Shedler: 1.Dysphoric personality disorder Subtypes A.Avoidant B.Dysphoric (essentially a high functioning neurotic) C.Emotionally dysregulated (similar to the borderline personality disorder) D.Dependent masochistic E.Dysphoric: Hostile-external (similar to passive-aggressive personality disorder) 2.Antisocial personality disorder 3.Schizoid personality disorder 4.Paranoid personality disorder 5.Obsessional personality disorder 6.Histrionic personality disorder 7.Narcissistic personality disorder These important studies conducted by Westen and Shedler have great relevance for developing a more adequate classification system and should be extended to Axis I disorders to determine if the methodology generalizes to this set of disorders. It is an important wedding of basic research and clinical activity.

Axis III: General Medical Conditions.This axis provides a way for clinicians to indicate any current physical conditions that they consider relevant to understanding or treating patients. Although Kendell (1983) urged that this axis be revised to include ‘‘all etiological factors, both proven and suspected, to purge the first two axes of all etiological implications’’, it was not revised for DSM-III-R or IV. Inclusion of this axis in no way implies that clinicians are expected to evaluate their patients physically, for most mental health practitioners (including psychiatrists) do not conduct physical examinations or make physical diagnoses. Nonetheless, a verbal screening for notable physical problems should be included as part of any clinician’s comprehensive evaluation. Axis IV: Psychosocial and Environmental Problems.This axis is for reporting psychosocial and environmental problems that may affect the diagnosis, treatment, and prognosis of the disorder. This axis changed considerably from the DSM-III and III-R and allows the examiner to note the presence of psychosocial stressors (e.g., poverty) that have contributed to the development or exacerbation of the disorder. Axis V: Global Assessment of Functioning. This axis had the largest revision in DSM-III-R. In DSM-III, it was labeled ‘‘highest level of adaptive functioning in the past year’’ and used a sevenpoint scale to assess adaptive functioning in terms of social relationships, occupational performance, and use of leisure time. The primary use of this scale was considered its potential prognostic validity, and DSM-III-R expanded the clinician’s ability to judge this area by specifying that the individual be assessed for current functioning as well as level of functioning during the past year. Comparing the two ratings is said to reflect both the current need for treatment and the degree of deviation from the individual’s premorbid functioning. In the DSM-IV, the patient is rated on a scale that gives the clinician’s judgment of the overall level of function from 0–100. However the GAF may reflect current functioning, functioning at discharge, or functioning in the past (i.e., GAF = 75 (past year) and GAF = 85 (current). Thus, a DSM-IV diagnosis might look like this: Axis I = 305.00, alcohol abuse; Axis II = 301.6 Dependent Personality Disorder; Axis IV = Unemployed; Axis V = 65 (current). The choice of these five axes was made after careful consideration. Williams noted that the committee sought to make the system comprehensive yet practical enough for routine clinical use. This limited the number of axes that could be included, although various authors have proposed separate axes for such areas as intelligence, substance abuse, family factors, and response to treatment. It is apparent that, despite its flaws, the DSM-IV and its successors represent a decided improvement over previous efforts. This system came about in response to the resurgence of the neoKraepelian movement in psychiatry—and hence continues to overemphasize the medical model— but at least criteria now exist that can be operationally evaluated. It is hoped that the heuristic value of the DSM series will lead to continued advancement in classifying abnormal behavior.

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