Handbook of Psychology, Clinical Psychology

Irving B. Weiner, George Stricker, Thomas A. Widiger

• Publisher: Wiley
• Year: 2012
• Print ISBN:
  9780470917992
• Edition: 2
• eBook ISBN:
  9781118404454
• Topic: Psychology
• Subtopic: History & Theory in Psychology
• Index: Psychology

Psychology is of interest to academics from many fields, as well as to the thousands of academic and clinical psychologists and general public who can't help but be interested in learning more about why humans think and behave as they do. This award-winning twelve-volume reference covers every aspect of the ever-fascinating discipline of psychology and represents the most current knowledge in the field. This ten-year revision now covers discoveries based in neuroscience, clinical psychology's new interest in evidence-based practice and mindfulness, and new findings in social, developmental, and forensic psychology.

Part I

Psychopathology

Chapter 1

Diagnosis and Classification

Thomas A. Widiger and Cristina Crego

Historical Background

Continuing Issues for ICD-11 and DSM-5

Conclusions

References

Human beings engage in a wide array of behaviors, including eating, sleeping, talking, feeling, thinking, playing, buying, and having sex. All of these forms of behavior include a maladaptive variant that is diagnosed as a mental disorder by the American Psychiatric Association. Dysfunctional, aberrant, and maladaptive feeling, thinking, behaving, and relating to others are of substantial concern to many different professions, the members of which hold an equally diverse array of opinions regarding etiology, pathology, and treatment. It is imperative that these persons be able to communicate meaningfully with one another. The primary purpose of an official diagnostic nomenclature is to provide this common language of communication (Kendell, 1975; Sartorius et al., 1993).

An official diagnostic nomenclature, however, can be an exceedingly powerful document, impacting many important social, forensic, clinical, and other professional decisions (Schwartz & Wiggins, 2002). Persons think in terms of their language and the predominant languages of psychopathology are the fourth edition of the American Psychiatric Association's (1994, 2000) Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR) and the 10th edition of the World Health Organization's (WHO) International Classification of Diseases (ICD-10; WHO, 1992). As such, these nomenclatures have a substantial impact on how clinicians, social agencies, the government, and the general public conceptualize aberrant, problematic, and maladaptive behavior.

Interpreting DSM-IV-TR or ICD-10 as conclusively validated nomenclatures, however, exaggerates the extent of their scientific support (Frances, Pincus, Widiger, Davis, & First, 1990; Frances & Widiger, in press). There is little within DSM-IV-TR or ICD-10 that is not subject to significant dispute. Mental disorders are to a substantial extent constructions of clinicians and researchers rather than proven, evident diseases or illnesses (Maddux, Gosselin, & Winstead, 2008). On the other hand, the diagnoses contained within DSM-IV-TR and ICD-10 are not necessarily lacking in credible or compelling empirical support. DSM-IV-TR and ICD-10 contain many flaws, but they are also well-reasoned, scientifically researched, and, for the most part, well-documented nomenclatures that describe what is currently understood by most scientists, theorists, researchers, and clinicians to be the predominant forms of psychopathology (Widiger, in press). This chapter overviews the DSM-IV-TR diagnostic nomenclature, beginning with historical background, followed by a discussion of the major issues facing the forthcoming DSM-5 and future revisions.

Historical Background

The impetus for the development of an official diagnostic nomenclature was the chaos and confusion generated by its absence (Widiger, 2001). “For a long time confusion reigned. Every self-respecting alienist [the 19th-century term for a psychiatrist], and certainly every professor, had his own classification” (Kendell, 1975, p. 87). For the young, aspiring professor, the production of a new system for classifying psychopathology was a standard rite of passage in the 19th century.

To produce a well-ordered classification almost seems to have become the unspoken ambition of every psychiatrist of industry and promise, as it is the ambition of a good tenor to strike a high C. This classificatory ambition was so conspicuous that the composer Berlioz was prompted to remark that after their studies have been completed a rhetorician writes a tragedy and a psychiatrist a classification. (Zilboorg, 1941, p. 450)

In 1908, the American Bureau of the Census asked the American Medico-Psychological Association (which subsequently altered its title in 1921 to the American Psychiatric Association) to develop a standard nosology to facilitate the obtainment of national statistics:

The present condition with respect to the classification of mental diseases is chaotic. Some states use no well-defined classification. In others the classifications used are similar in many respects but differ enough to prevent accurate comparisons. Some states have adopted a uniform system, while others leave the matter entirely to the individual hospitals. This condition of affairs discredits the science. (Salmon, Copp, May, Abbot, & Cotton, 1917, pp. 255–256)

The American Medico-Psychological Association, in collaboration with the National Committee for Mental Hygiene, issued a nosology in 1918, titled Statistical Manual for the Use of Institutions for the Insane (Menninger, 1963). This nomenclature, however, failed to obtain wide acceptance. It included only 22 diagnoses and these were confined largely to psychoses with a presumably neurobiological pathology. Therefore, “in the late twenties, each large teaching center employed a system of its own origination, no one of which met more than the immediate needs of the local institution” (American Psychiatric Association, 1952, p. v). There was no common, unified system of diagnosis. Patients being treated at one clinic were given different diagnoses than patients treated at another clinic. Consistent, accumulative research was difficult to produce as each researcher studied his or her own constructions, rarely building upon a common scientific base. A conference was held at the New York Academy of Medicine in 1928 to develop a more authoritative and uniformly accepted manual. The resulting nomenclature was modeled after the Statistical Manual but it was distributed to hospitals within the American Medical Association's Standard Classified Nomenclature of Disease. Many hospitals used this system but it eventually proved to be inadequate when the attention of the profession expanded well beyond psychotic disorders during World War II. ICD-6 and DSM-I

The Navy, Army, and Veterans Administration developed their own, largely independent nomenclatures during World War II due in large part to the inadequacies of the Standard Classified. “Military psychiatrists, induction station psychiatrists, and Veterans Administration psychiatrists, found themselves operating within the limits of a nomenclature specifically not designed for 90% of the cases handled” (American Psychiatric Association, 1952, p. vi). The World Health Organization (WHO) accepted the authority in 1948 to produce the sixth edition of the International Statistical Classification of Diseases, Injuries, and Causes of Death (ICD). ICD-6 was the first edition to include a section devoted to mental disorders (Kendell, 1975), perhaps in recognition of the many psychological casualties of World War II, as well as the increasing impact and contribution of mental health professions within the broader society. The United States Public Health Service commissioned a committee, chaired by the psychiatrist George Raines (notably though with representations from a variety of other professions and public health agencies) to develop a variant of the mental disorders section of ICD-6 for use within the United States. The United States, as a member of the WHO, was obliged to use ICD-6, but adjustments could be made to maximize the acceptance and utility of ICD-6 within the United States. The resulting nomenclature resembled closely the Veterans Administration system developed by Brigadier General William Menninger (brother to Karl Menninger, 1963). Responsibility for publishing and distributing this nosology was given to the American Psychiatric Association (1952) under the title Diagnostic and Statistical Manual: Mental Disorders (hereafter referred to as DSM-I).

DSM-I was generally successful in obtaining acceptance, due in large part to its expanded coverage, particularly the inclusion of somatoform disorders, stress reactions, and personality disorders. DSM-I also included narrative descriptions of each disorder to facilitate understanding and more consistent applications. Nevertheless, fundamental criticisms regarding the reliability and validity of psychiatric diagnosis were also being raised (e.g., Scheff, 1966; Szasz, 1960; Zigler & Phillips, 1961). For example, a widely cited reliability study by Ward, Beck, Mendelson, Mock, and Erbaugh (1962) concluded that most of the poor agreement among psychiatrists' diagnoses was due largely to inadequacies of DSM-I, and more specifically, its failure to provide specific, explicit guidelines as to the diagnostic criteria for each respective disorder, allowing clinicians to vary widely in how they applied the diagnostic system.

ICD-6 was even less successful. The “mental disorders section [of ICD-6] failed to gain [international] acceptance and eleven years later was found to be in official use only in Finland, New Zealand, Peru, Thailand, and the United Kingdom” (Kendell, 1975, p. 91). The WHO therefore commissioned a review by the English psychiatrist, Erwin Stengel. Stengel (1959) reiterated the importance of establishing an official nomenclature.

A…serious obstacle to progress in psychiatry is difficulty of communication. Everybody who has followed the literature and listened to discussions concerning mental illness soon discovers that psychiatrists, even those apparently sharing the same basic orientation, often do not speak the same language. They either use different terms for the same concepts, or the same term for different concepts, usually without being aware of it. It is sometimes argued that this is inevitable in the present state of psychiatric knowledge, but it is doubtful whether this is a valid excuse. (Stengel, 1959, p. 601)

Stengel (1959) attributed the failure of clinicians to accept the mental disorders section of ICD-6 to the presence of theoretical biases, cynicism regarding any psychiatric diagnoses (some theoretical perspectives opposed the use of any diagnostic terms), and the presence of abstract, highly inferential diagnostic criteria that hindered consistent, uniform applications by different clinicians.

ICD-8 and DSM-II

ICD-6 had been revised to ICD-7 in 1955 but there were no revisions to the mental disorders section. Work began on ICD-8 soon after Stengel's 1959 report. The final edition was approved by the WHO in 1966 and became effective in 1968. A companion glossary, in the spirit of Stengel's (1959) recommendations, was to be published conjointly, but work did not begin on the glossary until 1967 and it was not completed until 1972. “This delay greatly reduced [its] usefulness, and also [its] authority” (Kendell, 1975, p. 95). In 1965, the American Psychiatric Association appointed a committee, chaired by Ernest M. Gruenberg, to revise DSM-I to be compatible with ICD-8 and yet also be suitable for use within the United States. The final version was approved in 1967, with publication in 1968.

The diagnosis of mental disorders, however, was continuing to receive substantial criticism (e.g., Rosenhan, 1973). A fundamental problem continued to be the absence of empirical support for the reliability, let alone the validity, of its diagnoses (e.g., Blashfield & Draguns, 1976). Researchers, therefore, took to heart the recommendations of Stengel (1959) to develop more specific and explicit criterion sets (Blashfield, 1984). The most influential of these efforts was produced by a group of neurobiologically oriented psychiatrists at Washington University in St. Louis. Their criterion sets generated so much interest that they were published separately in what has become one of the most widely cited papers in psychiatry (i.e., Feighner et al., 1972).

The Feighner et al. (1972) criterion sets were confined to just the 15 disorders of primary interest to the Washington University researchers. Their approach to diagnosis was greatly expanded by Robert Spitzer (a technical consultant for DSM-II; American Psychiatric Association, 1968) into a manual that covered a much wider variety of diagnosis, titled the Research Diagnostic Criteria (RDC; Spitzer, Endicott, & Robins, 1978). The RDC was adopted by many research programs around the world, and contributed to the obtainment of more consistent and replicable research findings. This subsequent research using specific and explicit criterion sets assessed with structured interviews has since indicated that mental disorders can be diagnosed reliably and do provide valid information regarding etiology, pathology, course, and treatment (Kendler, Munoz, & Murphy, 2010).

ICD-9 and DSM-III

By the time Feighner et al. (1972) was published, work was nearing completion on ICD-9. The authors of ICD-9 had decided to include a glossary, but it was apparent that it would not include the more specific and explicit criterion sets developed and used in research (Kendell, 1975). In 1974, the American Psychiatric Association appointed a Task Force, chaired by Robert Spitzer, to revise DSM-II in a manner that would be compatible with ICD-9 but would also incorporate many of the advances in diagnosis currently being developed. DSM-III was published in 1980 and was remarkably innovative, including (a) a multiaxial di...

Table of contents

• Cover
• Title Page
• Copyright
• Editorial Board
• Handbook of Psychology Preface
• Volume Preface
• Contributors
• Part I: Psychopathology
• Part II: Psychotherapy
• Part III: Professional Issues
• Author Index
• Subject Index