CHAPTER FOUR

1. CHAPTER FOUR Classification of Abnormal Behavior DSM DSM

2. Classification • Classification (what it is and why we do it) • Classification systems • Description of the DSM-IV • Evaluation of the DSM-IV • Limitations of DSM-IV YOU ARE NOT RESPONSIBLE FOR THE ASSESSMENT SECTION

3. Classification • Classification (what it is and why we do it) • Classification systems • Description of the DSM-IV • Evaluation of the DSM-IV • Limitations of DSM-IV

4. What is classification? • Classification • subdividing or organizing a set of related objects • Animals, Historical Periods, and Music are subdivided and organized in various ways

5. Why use a classification system? • Benefit • a shared scientific language • facilitates description • aids treatment decisions, prognosis • facilitates research on etiology, treatment outcome • facilitates 3rd-party reimbursement (managed care system)

6. Why use a classification system? • Concerns • stigmatization and marginalization • expectations for behavior may change as result • unrelated problems may be misattributed to diagnosis Rosenhan’s Study

7. Classification • Classification (what it is and why we do it) • Classification systems • Description of the DSM-IV • Evaluation of the DSM-IV • Limitations of DSM-IV

8. DIAMOND COAL Describing Classification Systems What do the items in each group have in common? 1 2 Stroke Heart Attack 3

9. Categories vs. Dimensions • Categorical Approach • reflects a difference in kind or quality • Dimensional Approach • focuses on the amount of a particular characteristic an object possesses HEIGHT

10. not depressed | depressed Approaches to Classifying Abnormal Behavior • Categorical Approach • people with abnormal behaviors are qualitatively different from normal people (discrete groups)

11. Are you Depressed? • Yes • No

12. Categorical Approach

13. very depressed mildly depressed not at all depressed Approaches to Classifying Abnormal Behavior • Dimensional Approach • people with abnormal behaviors are quantitatively different (continuum) X = ?

14. How Depressed are you? Not at all Extremely 0 1 2 3 4

15. very depressed mildly depressed not at all depressed Approaches to Classifying Abnormal Behavior • Threshold Approach • combines categorical and dimensional X

16. How Depressed are you? Not at all Extremely 0 1 2 3 4 Legend: 0-1 = Not Depressed 2 and above = Depressed

17. Classification • Classification (what it is and why we do it) • Classification systems • Description of the DSM-IV • Evaluation of the DSM-IV • Limitations of DSM-IV

18. Description of DSM-IV System • Depends on observations and descriptions, rather than causes, which are often unknown • Categorical • Multi-Axial

19. Description of DSM-IV System • Axis I -- Clinical disorders • mostly characterized by episodic periods of psychological turmoil • Axis II -- Personality disorders and mental retardation • mostly concerned with stable, longstanding problems

20. Description of DSM-IV System • Axis III -- General Medical Conditions • conditions relevant to etiology of patient’s behavior or treatment program • Axis IV -- Psychosocial & EnvironmentalProblems • factors that may affect the treatment and prognosis of mental disorder

21. Description of DSM-IV System • Axis V -- Global Assessment of Functioning • rating of 1 to 100 of individual’s overall level of functioning • usually assessed at several points • highest in last year • at intake • Current The only axis that is dimensional

22. 90 -100 • Superior functioning in a wide range of activities, life’s problems never seem to get out of hand, is sought out by others because of his or her many positive qualities. No symptoms • 51-60 • Moderate symptoms (e.g., flat affect and circumstantial speech, occasional panic attacks) OR moderate difficulty in social, occupational, or school functioning (e.g., few friends, conflicts with peers or co-workers) • 1-10 • Persistent danger of severely hurting self or others (e.g., recurrent violence) OR persistent inability to maintain minimal personal hygiene or serious suicidal act with clear expectation of death

23. DSM-IV TR: Hypothetical Example Axis I: Major Depression, Recurrent, Mild Axis II: No diagnosis, frequent use of denial Axis III: Recurrent ear infections Axis IV: Victim of child neglect, 3 younger sibs Axis V: GAF = 56 (current) Remember Gary?

24. DSM-IV: A 5-Axis System The Case of “Gary” Axis I: R/O Major depressive disorder Axis II: Schizoid personality disorder Axis III: Arrhythmia Axis IV: Problems related to the social environment Axis V: 60 (current)

25. Hypothetical Example 2 specifiers Rule out Axis I: Major Depression, Recurrent, Mild        Alcoholism, in remission Bulimia Nervosa (provisional) Axis II: R/O Borderline Personality Disorder Axis III: Ovarian Cancer Axis IV: sexually abused as a child, rape-victim Axis V: GAF = 45 (at intake)

26. Classification • Classification (what it is and why we do it) • Classification systems • Description of the DSM-IV • Evaluation of the DSM-IV • Limitations of DSM-IV

27. Evaluation of DSM-IV • Reliability • consistency of measurements, including diagnostic decisions Reliability Test Clinician Observed/Predicted Outcome Test score or performance Diagnosis

28. Evaluation of DSM-IV • Inter-rater Reliability • refers to agreement of raters about observations

29. Evaluation of DSM-IV • Validity • meaning or importance of a classification system • conceptualized as a continuum of more to less useful (i.e., classification systems are more to less valid) • But valid for what? • We need to ask… how meaningful is it for a desired purpose? • Is the SAT valid? • (if we’re assessing aptitude, not artistic abilities)

30. 1 2 3 Reliable and Valid? LARRY CURLY MO

31. Validity Illustration Cook Book B Apple Pie: apples, tomatoes, lettuce, flour Burritos: beans, cinnamon, tortillas, sugar Cook Book A Apple Pie: apples, sugar, flour, cinnamon Burritos: beans, tortillas, tomatoes, lettuce

32. ICD10-DCR A. Exposure to stressor B. Persistent remembering of the stressor in one of: intrusive flashbacks, vivid memories or recurring dreams, experiencing distress when reminded of the stressor C. Requires only onesymptom of actual or preferred avoidance Either of D1 orD2: D1 inability to recall D2 two or more of: A. sleep problems B. Irritability C. concentration problems D. Hypervigilance E. exaggerated startle response E. Onset of symptoms within 6 months of the stressor DSM-IV A1. Exposure to stressor A2. Emotional reaction to stressor Requires one or more of: B1. Intrusive recollections B2. Distressing dreams B3. Acting/feeling as though event were recurring B4. Psychological distress when exposed to reminders B5. Physiological reactivity when exposed to reminders Requires three or more symptoms of: C1. avoidance of thoughts, feelings or conversations associated with the stressor C2. avoidance of activities, places or people associated with the stressor C3. inability to recall C4. diminished interest in significant activities C5. detachment from others C6. restricted affect C7. sense of foreshortened future Two or more of: D1. sleep problems D2. irritability D3. concentration problems D4. hypervigilance D5. exaggerated startle response E. Duration of the disturbance is at least 1 month F. Requires distress or impairment PTSD

33. Validity & Evaluation of DSM-IV • Types of Validity • Etiological • Concurrent • Predictive

34. Validity & Evaluation of DSM-IV • Etiological Validity • concerned with the specific factors that are regularly and perhaps uniquely associated with a particular disorder

35. Etiological Validity Classification System 1 Cause Disorder A A1 B B1 C C1 D D1 Classification System 2 Cause Disorder A A1 B B1 C C1 D D1

36. Validity & Evaluation of DSM-IV • Concurrent Validity • concerned with the present time and the association between disorder and other symptoms, life events and test performance

37. Validity & Evaluation of DSM-IV • Predictive Validity • concerned with the accuracy of predictingfuture treatment and treatment outcomes

38. Classification • Classification (what it is and why we do it) • Classification systems • Description of the DSM-IV • Evaluation of the DSM-IV • Limitations of DSM-IV

39. Limitations of the DSM-IV • Arbitrary boundary between normal and abnormal behavior • Cutoff points not always empirically justified • Reliance on clinicians’subjective judgment • Time periods in definitions of diagnoses

40. Limitations of the DSM-IV • Problem of Comorbidity • Simultaneous appearance of two or more disorders in the same person • 56% of those who meet criteria for one disorder also meet criteria for at least one other disorder • Comorbidity affects validity of the system and the reliability of diagnosis

41. Last Word on Classification(for now) • Beware of “Intern's Syndrome” Tendency to diagnose one's self while studying any particular disorder (“I do that!”) • look at frequency and severity of symptoms, as well as number of symptoms • check in with friends and or professionals about how you're doing

42. Optional Slides

43. Categorical Approach

44. Categorical Approach