Learning Objectives Importance of Classification Philosophical underpinnings of two approaches to classification Purposes of Classification Symbols and Language Words are symbols By convention we all agree on symbols ID: 581366
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Slide1
Classification of Psychological DisordersSlide2
Learning Objectives
Importance of Classification
Philosophical underpinnings of two approaches to classification
Purposes of ClassificationSlide3
Symbols and Language
Words are symbols
By convention we all agree on symbols
Why I can refer to a pen and we all know what it is I am referring to
If not, have to have pen directly in front of us.
How do we come to establish symbols or concepts that everyone can agree upon?
Nature of classificationSlide4
Classification
Important activity in clinical work and research
Basic part of science
Information made more accessible, meaningful, and less cumbersomeSlide5
Classification
Normal vs. Abnormal
Charles MansonSlide6
Classification
Need to further define abnormal
Divide “abnormal” into subclasses
Mushroom exampleSlide7
Mushroom
Not a MushroomSlide8
Poisonous
EdibleSlide9
Bach Mai Hospital doctors treat the oldest of two brothers who survived eating poisonous mushrooms, although six of their families members did die. Slide10
Classification Historical
Paradigms have influenced how classification done and what was classified
Hippocrates’ Four humors:Slide11
Hippocrates
1. Black Bile ----
Depression
2. Yellow Bile ---- Tension/Anxiety
3. Phlegm ---- Dull, Sluggishness
4. Blood ---- Mania/Mood SwingsSlide12
Historical
Pre-history: Likely simply divided into normal vs abnormal
Ancient Greece: Hippocrates
Others over the ages: Jean Fernel (1497 – 1588); Feliz Platter (1536-1614); Francois Baussier de Sauvages (18
th
C)Slide13
Philosophical Issues in Abnormal Behaviour
Paradigms
Nature of psychopathology, normalcy, belief in paradigm
Historical
Emil
Kraeplin
and Neo-
Kraeplians
Sigmund Freud
Contemporary:
DSM & ICDPDM & OPDS
Slide14
Two Trends
Symptom as Focus (
Kraeplin
)
Underlying Cause as Focus (Freud)Slide15
Symptom as Focus
Group of
Sx
or observable behaviors
Seen as cause of the difficulties
Focus of assessment and treatment is on eradicating the symptoms
Behavior school, ICD, DSM
Variant embraced by Managed Care in US (i.e., insurance company)Slide16
Underlying Cause as Focus
Problems caused by underlying process
Assessment and treatment focuses on underlying process
Orientation of psychodynamic, cognitive behavioral (to degree), and PDM.Slide17
Classification
Basic part of science
Want to make information more accessible, meaningful, and less cumbersomeSlide18
Classification - Purposes
Description and need to identify
Communication
Research
Treatment
Insurance
Theory Development
Epidemiological InformationSlide19
Diagnosis leads to treatment
From medical perspective:
Appendicitis
Gas PainsSlide20
Diagnosis does not always lead to proper treatment:
Alzheimer’s Disease
Depression and “families” of
drugs
ALSSlide21
How to Classify?
Divide disorders into mutually exclusive and collectively exhaustive subclasses
Mutually Exclusive: disorders should be distinct and cannot belong to two different subclasses (e.g., poisonous and edible mushrooms???)
Collectively Exhaustive: all disorders must be classifiedSlide22
How to Classify? Cont’d
Subclasses defined by necessary and sufficient conditions
Must be characteristics that are necessary for classification
Must also be set of sufficient conditions to belong to a subclassSlide23
How to Classify Cont’d
Reliability:
Each time you (or someone else) uses the classification system, should get the same result
Need to identify psychological problems in a clear and reliable manner
Also need agreement among mental health professionals or can have individuals referring to same term to describe different disorders
E.G., Schizophrenia and “split personality” (i.e., dissociative identity disorder)Slide24
How to Classify Cont’d
Validity:
Classification system should say something about the “true world”Slide25
DSM – IV Text RevisionSlide26
DSM’S
Categorical Approach to define abnormality
Revised periodically:
DSM first published 1952
DSM II published 1968
DSM III published 1980
DSM III Revised published 1987
DSM IV published 1994
DSM IV Text Revision 2000
DSM
V published 2014Slide27
DSM
Over 400 disorders
DSM provides descriptive information not based on any one theoretical perspective (although this is
debateable
)
Categorical Approach
Descriptive features are based on observable features:Slide28
DSM IV TR
Provides information on:
Diagnostic Features
Associated Features and Disorders
Associated Laboratory Findings
Age-related, Culture-related and Gender-related features
Slide29
DSM 4 & 5
DSM 4 – 5 axes
DSM 5 - No
Axes – Different DisordersSlide30
Pros and Cons
Pro:
Reliability has improved over previous editions
Provides information on research and reliable and valid information
Axis IV and V very good in terms of attempting to take into account many factorsSlide31
Pros and Cons
Con:
Only first 3 Axes tend to used and even then Axis 2 used inappropriately
Labeling and stigma still issue
Biological tests not used
Fees paid based on diagnosis and some patients diagnosed inappropriately
Doesn’t lead to differential treatment decisions for most part
Still very subjectiveSlide32
DSM IVTR (p. XXXIV)
“ DSM-IV is a categorical classification that divides mental disorders into types based on criteria sets with defining features….. In DSM-IV there is no assumption that each category of mental disorder is a completely discrete entity with absolute boundaries dividing it from other mental disorders or from no mental disorder”Slide33
Diagnosis and Formulation
Diagnosis: Assigning diagnostic category
Formulation: Attempt to explain genesis, maintenance, and process related information for treatment
Struct
. Interview
Diagnosis
Assessment FormulationSlide34
Most clinicians agree that need both, although likely majority indicate that formulation is actually more importantSlide35
Other Diagnostic Manuals in UseSlide36
Other Diagnostic Manuals in UseSlide37
Psychodynamic Diagnostic Manual (PDM)Slide38
PDM
DSM provides one level of description
Some argue don’t measure some of the most important things
PDM:
there is more to people than what is described in DSM
Attempts to describe and categorize elements not found in DSM
Attempts to provide information that will improve comprehensive treatments
Slide39
PDM
Not developed to supplant DSM but to supplement DSM
Developed from a theoretical perspective: Current Psychodynamic Theory:
Psychoanalysis
Object Relations
Attachment TheorySlide40
PDM
Diagnostic framework
Describes the whole person:
Surface and deeper levels of personality, person’s emotional and social functioning
Based on current neuroscience and treatment outcome studiesSlide41
PDM Developed By
American Psychoanalytic Association
American Academy of Psychoanalysis
International Psychoanalytic Association
American Psychological Association Division 39
National Membership Committee on Psychoanalysis in Clinical Social WorkSlide42
PDM
The elements include:
Personality patterns
Social and emotional capacities
Unique mental profiles
Personal experiences of individualsSlide43
PDM- Rationale
Human
behaviour
is complex
DSM simplifies
behaviour
too much
Want to direct focus on full range of affect, thought,
behaviour
in context of an individual’s own unique historySlide44
PDM- Rationale Cont’d
Consistent with idea that:
Rather than thinking of people having discrete disorders (i.e., ego dystonic, separate, outside of self), see disorders as result of some process (personality, incorporation of upbringing, etc.) and the process is what is importantSlide45
PDM Dimensions
Personality Patterns and Disorders (P Axis)
Mental Functioning (M Axis)
Manifest Symptoms and Concerns (S Axis)Slide46
P Axis
Person’s location on Continuum:
Healthy -----------------Disordered
Ways in which person organizes mental functioning and interacts with world
Maxim: Need to understand person in order to understand problemSlide47
P Axis
Includes many of the Axis II diagnoses from DSM
Adds other ones that are seen as extremely important:
Depressive Personality Disorder
Sadistic and Sadomasochistic PD
Masochistic (Self-defeating) PD
Somatizing PD
Dissociative PDSlide48
M Axis
Detailed look at emotional functioning
E.G., Information processing, self-regulation, relationships, emotional expression, learning, coping/defenses, etc.Slide49
S Axis
Using the DSM categories, focus on personal experience of difficulties
Need to be seen in context of personality and mental functioningSlide50
PDM
Attempt to develop a thorough and comprehensive diagnostic picture
Takes whole person into accountSlide51
PDM
Published in 2006 so little early to evaluate
Welcomed by most clinicians as an addition to aid in treatment planning
Aids in formulation:
Diagnosis doesn’t give you all relevant information for treatment
Need to determine etiology, maintenance factors, process-related issues, history of relationships, etc. which guide treatmentSlide52
Other Classification Systems
ICD – 10
McLemore and Benjamin’s Interpersonal Diagnosis
Operationalised
Psychodynamic SystemSlide53
Classification
Discrete?
Can people be placed in a neat diagnostic box or not?Slide54
Discrete Categories
Female
Not Pregnant
Male
PregnantSlide55
Classification
Continuous?
Are the disorders on a continuum?
Nondepressed Depressed
Slide56
Discrete Categories?
Not Depressed
Abnormal
Depressed
Normal