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1. Diagnosis and Classification Issues
Chapter 7

2. Defining Normality and
Abnormality (1 of 6)
What Defines Abnormality?
• Personal distress to the individual
• Deviance from cultural norms
• Statistical infrequency
• Impaired social functioning
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3. Defining Normality and
Abnormality (2 of 6)
What Defines Abnormality?
• Harmful Dysfunction Theory
– Disorder a harmful dysfunction
• Harmful: value term based on social norms
• Dysfunction: failure of mental mechanism to
perform a function naturally
– Concept combines value and scientific
components
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4. Defining Normality and
Abnormality (3 of 6)
Who Defines Abnormality?
• Diagnostic and Statistical Manual of Mental
Disorders (DSM)
– Defines mental disorder as a clinically significant
disturbance in cognition, emotion regulation, and
behavior
– Indicates a dysfunction in mental functioning
– Expectable reactions to common stressors are
not mental disorders
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5. Defining Normality and
Abnormality (4 of 6)
Who Defines Abnormality?
• Diagnostic and Statistical Manual of
Mental Disorders (DSM)
– Reflects a medical model of psychopathology
– Each disorder categorically listed and defined
with a list of specific symptoms
– Culture and values of those defining disorders
play influential role in the definitions produced
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6. Defining Normality and
Abnormality (5 of 6)
Why Is the Definition of Abnormality
Important?: Importance for Professionals
• Presence or absence of a diagnostic label
strongly impacts attention it receives from
clinical psychologists
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7. Defining Normality and
Abnormality (6 of 6)
Why Is the Definition of Abnormality
Important?: Importance for Clients
• No diagnosis in absence of label
• Label could
– Lead to stereotyping of individuals
– Have an effect on outcome of legal issues
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8. Diagnosis and Classification of
Mental Disorders: A Brief History
(1 of 30)
Before the DSM
• Discussions of abnormal behavior appear
in ancient Chinese, Hebrew, Egyptian,
Greek, and Roman texts
• Hippocrates’ theories of abnormality
emphasized natural causes
– Was a significant early step to current
definitions
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9. Diagnosis and Classification of
Mental Disorders: A Brief History
(2 of 30)
Before the DSM
• Mental asylums established in Europe and
U.S. in the 19th century
• Helped to categorize disorders
• Evolution of common terminology
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10. Diagnosis and Classification of
Mental Disorders: A Brief History
(3 of 30)
Before the DSM
• Emil Kraepelin founding father of current
diagnostic system
– Labeled specific categories, such as manic-
depressive psychosis and dementia praecox
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11. Diagnosis and Classification of
Mental Disorders: A Brief History
(4 of 30)
Before the DSM
• Late 1800s and early 1900s
– Collection of statistical and census data primary
purpose of diagnostic categories
• Mid-1900s Veterans Affairs developed own
early categorization system
– To facilitate diagnosis and treatment of soldiers
returning from World War II
– Had significant influence on creation of first DSM
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12. Diagnosis and Classification of
Mental Disorders: A Brief History
(5 of 30)
DSM—Earlier Editions (I and II)
• DSM-I published by APA in 1952
• Revision published as DSM-II in 1968
• Both similar to each other
• Different from subsequent DSM editions
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13. Diagnosis and Classification of
Mental Disorders: A Brief History
(6 of 30)
DSM—Earlier Editions (I and II)
• Defined only three categories
– Psychoses
– Neuroses
– Character disorders
• Definitions of disorders not scientifically
or empirically based
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14. Diagnosis and Classification of
Mental Disorders: A Brief History
(7 of 30)
DSM—Earlier Editions (I and II)
• Language reflected psychoanalytic approach
to understanding people and their problems
• Vague descriptions of clinical conditions
described in prose
• Specific symptoms or criteria not listed
• Very limited generalizability or utility for
clinicians
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15. Diagnosis and Classification of
Mental Disorders: A Brief History
(8 of 30)
DSM—More Recent Editions (III, III-R, IV,
and IV-TR
• DSM-III (1980)
– Dissimilar to DSM-I and DSM-II
– Relied on empirical data
– Used specific diagnostic criteria to define
disorders
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16. Diagnosis and Classification of
Mental Disorders: A Brief History
(9 of 30)
DSM—More Recent Editions (III, III-R, IV, and
IV-TR
• DSM-III
– Psychoanalytic language replaced by terminology
that reflected no single school of thought
– Multiaxial assessment system
– Longer and more expansive than predecessors
– Included many new disorders
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17. Diagnosis and Classification of
Mental Disorders: A Brief History
(10 of 30)
DSM—More Recent Editions (III, III-R, IV,
and IV-TR
• DSM-III-R, DSM-IV, DSM-IV-TR
– Retained major changes introduced by DSM-
III
– Introduced significant other changes
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18. Diagnosis and Classification of
Mental Disorders: A Brief History
(11 of 30)
DSM-5: The Current Edition
• Published in 2013
• First substantial revision after 20 years
• Led by David Kupfer and Darrel Regier
• Researched over 12 years
• Coordinated efforts with WHO
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19. Diagnosis and Classification of
Mental Disorders: A Brief History
(12 of 30)
DSM-5: The Current Edition
• Steps
– Creation of Task Force
– Work groups
– Scientific Review Committee
– Field trials
– Website dsm5.org to communicate progress
to public
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20. Diagnosis and Classification of
Mental Disorders: A Brief History
(13 of 30)
DSM-5: The Current Edition—Changes
DSM-5 Did Not Make
• Changes considered but not made
– Use of biological markers as diagnostic tools
– Rating of disorders/symptoms on a scale
– Dimensional approach toward a disorder
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21. Diagnosis and Classification of
Mental Disorders: A Brief History
(14 of 30)
DSM-5: The Current Edition—Changes
DSM-5 Did Not Make
• Rejections of new disorders
– Attenuated psychosis syndrome
– Mixed anxiety-depressive disorder
– Internet gaming disorder
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22. Diagnosis and Classification of
Mental Disorders: A Brief History
(15 of 30)
DSM-5: The Current Edition—New Features
in DSM-5
• Title change to DSM-5
• Dropped multiaxial assessment system
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23. Diagnosis and Classification of
Mental Disorders: A Brief History
(16 of 30)
DSM-5: The Current Edition—New
Disorders in DSM-5
• Premenstrual dysphoric disorder
• Disruptive mood dysregulation disorder
• Binge eating disorder
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24. Diagnosis and Classification of
Mental Disorders: A Brief History
(17 of 30)
DSM-5: The Current Edition—New
Disorders in DSM-5
• Mild neurocognitive disorder (mild NCD)
• Somatic symptom disorder (SSD)
• Hoarding disorder
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25. Diagnosis and Classification of
Mental Disorders: A Brief History
(18 of 30)
DSM-5: The Current Edition—Revised
Disorders in DSM-5
• Bereavement exclusion
• Autism spectrum disorder
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26. Diagnosis and Classification of
Mental Disorders: A Brief History
(19 of 30)
DSM-5: The Current Edition—Revised
Disorders in DSM-5
• Attention-deficit/hyperactivity disorder
– Increased age of symptoms from 7 to 12
– Minimum number of symptoms in adults
increased to 5
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27. Diagnosis and Classification of
Mental Disorders: A Brief History
(20 of 30)
DSM-5: The Current Edition—Revised
Disorders in DSM-5
• Bulimia nervosa
– Frequency of binge eating reduced to
once/week
• Anorexia nervosa
– Reduction of less than 85% of the body
weight
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28. Diagnosis and Classification of
Mental Disorders: A Brief History
(21 of 30)
DSM-5: The Current Edition—Revised
Disorders in DSM-5
• Substance use disorder
• Mental retardation renamed intellectual
disability or intellectual development
disorder
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29. Diagnosis and Classification of
Mental Disorders: A Brief History
(22 of 30)
DSM-5: The Current Edition—Revised
Disorders in DSM-5
• Learning disabilities in math, reading, and
writing combined as specific learning
disorder
• Obsessive Compulsion Disorder removed
from Anxiety Disorders to new category
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30. Diagnosis and Classification of
Mental Disorders: A Brief History
(23 of 30)
DSM-5: The Current Edition—Revised
Disorders in DSM-5
• Mood Disorders split into two
– Depressive Disorders
– Bipolar and related disorders
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31. Diagnosis and Classification of
Mental Disorders: A Brief History
(24 of 30)
DSM-5: The Current Edition—Controversy
Surrounding DSM-5
• Many “work group” members quit midway
• Leaders of mental health organizations
boycotted DSM-5
• Most vocal critic was Allen Frances
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32. Diagnosis and Classification of
Mental Disorders: A Brief History
(25 of 30)
DSM-5: The Current Edition—Controversy
Surrounding DSM-5
• Allen Frances’ criticism
– Changes unsafe and scientifically unsound
– Medical illnesses diagnosed as somatic
symptom disorder
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33. Diagnosis and Classification of
Mental Disorders: A Brief History
(26 of 30)
DSM-5: The Current Edition—Controversy
Surrounding DSM-5
• Allen Frances’ criticism
– DSM-5 will mislabel normal people, promote
diagnostic inflation, encourage inappropriate
medication use
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34. Diagnosis and Classification of
Mental Disorders: A Brief History
(27 of 30)
DSM-5: The Current Edition—Controversy
Surrounding DSM-5
• Specific criticism by others
– Diagnostic overexpansion
– Transparency of the revision process
– Membership of the Work Groups
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35. Diagnosis and Classification of
Mental Disorders: A Brief History
(28 of 30)
DSM-5: The Current Edition—Controversy
Surrounding DSM-5
• Specific criticism by others
– Field trial problems
– Price
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36. Diagnosis and Classification of
Mental Disorders: A Brief History
(29 of 30)
Criticisms of the DSM
• Recent editions of DSM widely used by all mental
health professions
• Strengths
– Emphasis on empirical research
– Use of explicit diagnostic criteria
– Interclinician reliability
– Atheoretical language
– Facilitated communication between researchers and
clinicians
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37. Diagnosis and Classification of
Mental Disorders: A Brief History
(30 OF 30)
Criticisms of the DSM
• Breadth of coverage
• Controversial cutoffs
• Cultural issues
• Gender bias
• Nonempirical influences
• Limitations on objectivity
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38. Alternative Directions in
Diagnosis and Classification
• Categorical Approach
• Dimensional Approach
– Five-factor model of personality
• Neuroticism
• Extraversion
• Openness to experience
• Agreeableness
• Conscientiousness
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