Adult Psychopathology and Diagnosis

Michel Hersen, Samuel M. Turner, Deborah C. Beidel, Michel Hersen, Samuel M. Turner, Deborah C. Beidel

• Publisher: Wiley
• Year: 2011
• Print ISBN: 9780471745846
• eBook ISBN: 9781118046326
• Edition: 5
• Topic: Psychology
• Subtopic: Psychopathology
• Index: Psychology

The most up-to-date coverage on adult psychopathology

Adult Psychopathology and Diagnosis, Fifth Edition offers comprehensive coverage of the major psychological disorders and presents a balanced integration of empirical data and diagnostic criteria to demonstrate the basis for individual diagnoses. The accessible format and case study approach provide the opportunity to understand how diagnoses are reached.

Updated to reflect the rapid developments in the field of psychopathology, this Fifth Edition encompasses the most current research in the field including:

• A thorough introduction to the principles of the DSM-IV-TR classification system and its application in clinical practice
• The biological and neurological foundations of disorders and the implications of psychopharmacology in treatment
• Illustrative case material as well as clinical discussions addressing specific disorders, diagnostic criteria, major theories of etiology, and issues of assessment and measurement
• Coverage of the major diagnostic entities and problems seen in daily clinical work by those in hospitals, clinics, and private practice
• A new chapter on race and ethnicity by renowned expert Stanley Sue

PART I

OVERVIEW

CHAPTER 1

Mental Disorders as Discrete Clinical Conditions: Dimensional versus Categorical Classification

THOMAS A. WIDIGER AND STEPHANIE MULLINS-SWEATT

“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” (American Psychiatric mental disorders or from no mental disorder” (American Psychiatric Association [APA], 2000, p. xxxi). This carefully worded disclaimer, however, is somewhat hollow, as it is the case that “DSM-IV is a categorical classification that divides mental disorders into types based on criterion sets with defining features” (APA, 2000, p. xxxi). Researchers and clinicians, following this lead, diagnose and interpret the conditions presented in DSM-IV as disorders that are qualitatively distinct from normal functioning and from one another.

The question of whether mental disorders are discrete clinical conditions or arbitrary distinctions along dimensions of functioning is a long-standing issue (Kendell, 1975), but its significance is escalating with the growing recognition of the limitations of the categorical model (Widiger & Clark, 2000; Widiger & Samuel, 2005). “Indeed, in the last 20 years, the categorical approach has been increasingly questioned as evidence has accumulated that the so-called categorical disorders like major depressive disorder and anxiety disorders, and schizophrenia and bipolar disorder seem to merge imperceptibly both into one another and into normality ... with no demonstrable natural boundaries” (First, 2003, p. 661). In 1999, a DSM-V Research Planning Conference was held under joint sponsorship of the APA and the National Institute of Mental Health (NIMH), the purpose of which was to set research priorities that would optimally inform future classifications. One impetus for this effort was the frustration with the existing nomenclature.

In the more than 30 years since the introduction of the Feighner criteria by Robins and Guze, which eventually led to DSM-III, the goal of validating these syndromes and discovering common etiologies has remained elusive. Despite many proposed candidates, not one laboratory marker has been found to be specific in identifying any of the DSM-defined syndromes. Epidemiologic and clinical studies have shown extremely high rates of comorbidities among the disorders, undermining the hypothesis that the syndromes represent distinct etiologies. Furthermore, epidemiologic studies have shown a high degree of short-term diagnostic instability for many disorders. With regard to treatment, lack of treatment specificity is the rule rather than the exception. (Kupfer, First, & Regier, 2002, p. xviii)

DSM-V Research Planning Work Groups were formed to develop white papers that would set an effective research agenda. The Nomenclature Work Group, charged with addressing fundamental assumptions of the diagnostic system, concluded that it will be “important that consideration be given to advantages and disadvantages of basing part or all of DSM-V on dimensions rather than categories” (Rounsaville et al., 2002, p. 12).

The purpose of this chapter is to review the DSM-IV categorical diagnosis. The chapter begins with a discussion of fundamental categorical distinctions, including the boundaries with normality and among the existing diagnoses (the boundary with physical disorders was discussed briefly in a prior version of this chapter; Widiger, 1997). Reasons for maintaining a categorical model will then be considered. The chapter concludes with a recommendation for an eventual conversion to a more quantitative, dimensional classification of mental disorders.

BOUNDARY WITH NORMALITY

“In DSM-IV, each of the mental disorders is conceptualized as a clinically significant behavioral or psychological syndrome or pattern that occurs in an individual and that is associated with present distress (e.g., a painful symptom) or disability (i.e., impairment in one or more important areas of functioning) or with a significantly increased risk of suffering death, pain, disability, or an important loss of freedom” (APA, 2000, p. xxxi). If one considers the fundamental, defining features of a mental disorder, it is perhaps apparent that it would not be realistic for a qualitative distinction between normal and abnormal functioning to exist. This will be illustrated with respect to dyscontrol, impairment, and pathology—fundamental components of most concepts of mental disorder (Bergner, 1997; Klein, 1978, 1999; Spitzer & Williams, 1982; Wakefield, 1992; Widiger & Sankis, 2000; Widiger & Trull, 1991).

DYSCONTROL

Central to the concept of a mental disorder is dyscontrol (Bergner, 1997; Klein, 1999; Widiger & Trull, 1991). A mental disorder as an “involuntary organismic impairment in psychological functioning” (Widiger & Trull, 1991, p. 112; our emphasis). “Involuntary impairment remains the key inference” (Klein, 1999, p. 424). Dyscontrol is not within the concept of a physical disorder, but it is fundamental to a mental disorder, as the latter concerns impairments to feelings, thoughts, and behaviors over which normal, healthy persons attempt to exert volitional or regulatory control.

Persons who freely choose to engage in harmful or impairing behaviors would not be said to have a mental disorder. Presumably, persons can choose to consume alcohol, take anabolic steroids, shoot heroin, gamble, steal, assault, or engage in deviant sexual acts without being compelled to do so by the presence of a mental disorder. Gambling, drug usage, theft, assaults, and deviant sexual acts can be harmful and maladaptive, but the occurrence of a harmful (or deviant) act would not itself constitute a mental disorder (Gorenstein, 1984; Wakefield, 1992; Widiger & Trull, 1991). Similarly, to the extent that a person can control, modulate, manage, or regulate painful or harmful feelings of sadness, anxiety, or anger, the person would not be considered to have a mood or anxiety disorder (Widiger & Sankis, 2000). “It is the ability to flexibly adjust the way one regulates one’s emotions to environmental exigencies that is related to mental health” (Gross & Munoz, 1995, p. 151). It is when a person lacks sufficient control of mood, anxiety, or a harmful behavior pattern that a person might be diagnosed with a mental disorder (Frances, Widiger, & Sabshin, 1991).

There is, however, no qualitative distinction between the presence and absence of self-control. It is not even clear how much volitional or regulatory control a normal, healthy person has over adaptive, healthy behaviors (Bargh & Ferguson, 2000; Howard & Conway, 1986; Kirsch & Lynn, 2000; Wegner & Wheatley, 2000). Both normal and abnormal human functioning is, at best, the result of a complex interaction of apparent volitional choice with an array of biogenetic and environmental determinants.

A continuum (or ambiguity) of self-control is particularly evident in those disorders that involve behaviors that provide immediate benefits or pleasures to the person, such as pedophilia, intermittent explosive disorder, transvestic fetishism, kleptomania, antisocial personality, bulimia nervosa, anorexia nervosa, pathological gambling, and substance-related disorders such as alcohol abuse, cocaine abuse, anabolic steroid abuse, and nicotine dependence. These disorders are difficult to diagnose and are often controversial precisely because there is no distinct point at which dyscontrol occurs (Widiger & Smith, 1994). At one time, persons with alcohol dependence were thought to have a discrete pathology that rendered them entirely incapable of any control of their drinking. However, there is now sufficient research to indicate that persons vary in the extent to which they have inadequate control (Hyman, 2005; Kalivas & Volkow, 2005; Peele, 1984). Treatment for the purpose of controlled drinking is controversial because there is no absolute point of demarcation and persons who lack sufficient control will also lack an adequate awareness of their dyscontrol (Vaillant, 1995). In sum, determination of adequate versus inadequate self-control is fundamental to many social and clinical decisions, but the boundary is at best grossly ill-defined and poorly understood (Alper, 1998; Hyman, 2005; Kalivas & Volkow, 2005).

IMPAIRMENT

An additional fundamental feature of mental disorders is impairment (APA, 1994, 2000; Wakefield, 1992; Widiger & Trull, 1991). “The definition of mental disorder in the introduction to DSM-IV requires that there be clinically significant impairment” (APA, 2000, p. 8). The purpose of this requirement is to distinguish between a mental disorder and simply a problem in living. “The ever-increasing number of new categories meant to describe the less impaired outpatient population raises the question of where psychopathology ends and the wear and tear of everyday life begins” (Frances, First, & Pincus, 1995, p. 15).

To highlight the importance of considering this issue, the criteria sets for most disorders include a clinical significance criterion (usually worded “... causes clinically significant ... impairment in social, occupational, or other important areas of functioning”). This criterion helps establish the threshold for the diagnosis of a disorder in those situations in which the symptomatic presentation by itself (particularly in its milder forms) is not inherently pathological and may be encountered in individuals for whom a diagnosis of “mental disorder” would be inappropriate. (APA, 2000, p. 8)

DSM-III-R (APA, 1987) failed to include this requirement within the criterion sets for many of the disorders, contributing to a confusion of apparently harmless deviances, eccentricities, peculiarities, or annoyances with the presence of a mental disorder (Frances et al., 1991). For example, in DSM-III-R the attention-deficit hyperactivity and oppositional defiant disorders were diagnosed even if the behaviors resulted in “only minimal or no impairment in school and social functioning” (APA, 1987, pp. 53, 58). Similarly, transvestic fetishism could be diagnosed with DSM-III-R simply on the basis of intense sexual urges, fantasies, and behaviors involving cross-dressing that continued for more than six months (APA, 1987). A man who engaged in this behavior for longer than six months but experienced no impairment in functioning would still have been considered in DSM-III-R to have been mentally ill solely because he engaged in deviant sexual acts for longer than six months. It is possible that a six-month duration is a valid indicator for impairment (as well as dyscontrol) but (assuming that volitional behavior does exist) deviant sexual preferences could also be largely harmless. Therefore, DSM-IV required that “the fantasies, sexual urges, or behaviors cause clinically significant distress or impairment in social, occupational, or other important areas of functioning” (APA, 1994, p. 531).

However, nowhere in DSM-IV is a “clinically significant” impairment defined, not even within the section of the manual identified by the heading “Criteria for Clinical Significance” (APA, 2000, p. 8). It is only stated that this “is an inherently difficult clinical judgment” (APA, 2000, p. 8), and it is advised that the clinician consider information obtained from family members and other third parties. Frances et al. (1995) in fact stated that “the evaluation of clinical significance is likely to vary in different cultures and to depend on the availability and interests of clinicians” (p. 15). Absence of a clear basis for the judgment has also helped fuel the considerable controversy of premenstrual dysphoric disorder, a mental disorder that is diagnosed when normal premenstrual experiences (that occur in a substantial proportion of normal adult women) reach an ill-defined level of clinically significant impairment (Winstead & Sanchez, 2005).

Spitzer and Williams (1982), the original authors of the DSM-IV definition of mental disorder, defined a clinically significant impairment as that point at which the attention of a clinician is indicated. “There are many behavioral or psychological conditions that can be considered ‘pathological’ but the clinical manifestations of which are so mild that clinical attention is not indicated” (p. 166). They provided three examples: caffeine withdrawal, jet lag syndrome, and insomnia because of environmental noise. Impairments in each case were considered by Spitzer and Williams to be too small to be “justified as syndromes that were clinically significant to mental health professionals” (p. 166). These three examples, however, proved to be ironic, as jet lag syndrome was actually included within DSM-III-R as a variant of sleep-wake schedule disorder (APA, 1987, p. 306); caffeine withdrawal was subsequently included in the appendix to DSM-IV (APA, 1994); and a strong case has been made for the inclusion of caffeine dependence (Hughes, Oliveto, Helzer, Higgins, & Bickel, 1992).

What is considered to be a sufficient level of impairment to warrant treatment probably varies substantially across patients and across clinicians (Samuel & Widiger, in press) as well as often being below the threshold for many of the existing DSM-IV criterion sets. Clark, Watson, and Reynolds (1995) documented well the reliance of clinicians on the category of “not otherwise specified” (NOS) to diagnose subthreshold cases. Whenever this catchall diagnosis is included within a study, it is often the most frequent diagnosis, as in the case of mood disorders (Angst, 1992), dissociative disorders (Spiegel & Cardena, 1991), and personality disorders (Verheul & Widiger, 2004).

New additions to the diagnostic manual rarely concern newly discovered forms of psychopathology; instead, they are typically efforts to plug holes in between existing diagnosis and normal functioning (as well as filling gaps among the existing diagnoses). For example, acute stress disorder is essentially posttraumatic stress disorder with a shorter duration; recurrent brief depressive disorder is major depression with shorter episodes; mixed anxiety-depressive disorder concerns subthreshold cases of mood and anxiety disorders; binge eating disorder concerns subthreshold cases of bulimia nervosa; and mild neurocognitive disorder concerns subthreshold cases of dementia, delirium, or amnestic disorder (Frances et al., 1995). A fundamental difficulty shared by all of these diagnoses is the lack of a clear distinction with normal functioning. Two cases that illustrate well the absence of a clear boundary between normal and abnormal functioning are minor depressive disorder (which is considered to be a mental disorder, although not yet officially recognized) and age-related cognitive decline (which is not considered to be a mental disorder).

Minor depressive disorder was a new addition to DSM-IV that attempted to plug the gap between DSM-III-R mood disorder and normal sadness. There is considerable reluctance to add a new diagnosis for subthreshold depression (Pincus, McQueen, & Elinson, 2003), but it has been estimated that up to 50% of depressive symptomatology is currently being treated by primary care physicians without any consultation or involvement of a mental health clinician in part because the depression is below the threshold of a mood disorder diagnosis (Munoz, Hollon, McGrath, Rehm, & VandenBos, 1994). Many of these persons would meet the DSM-IV criteria for minor depressive disorder. However, it is acknowledged in DSM-IV that “symptoms meeting... criteria for minor depressive disorder can be difficult to distinguish from periods of sadness that are an inherent part of everyday life” (APA, 2000, p. 776). Only two distinctions are provided, one of which is a two-week duration. If a person is sad for less than two weeks, it is normal sadness. If it lasts longer than two weeks, it is a mental disorder. This is comparable to diagnosing cross-dressing as a transvestic fetishism if it is done longer than six months (APA, 1987). The second distinction is that “the depressive symptoms must cause clinically significant distress or impairment” (APA, 2000, p. 776) but, again, clinical significance is left undefined.

Age-related cognitive decline was a new addition to the section of the manual for conditions that are not mental disorders but might be the focus of clinical attention. “Cognitive decline in the elderly can be considered dimensionally ..., involving aging-associated cognitive decline, mild cognitive impairment, and dementia” (Caine, 1994, p. 335). “It may be very difficult to establish an arbitrary or numerical level wh...

Table of contents

• Title Page
• Copyright Page
• Preface
• Contributors
• PART I - OVERVIEW
• PART II - SPECIFIC DISORDERS
• Author Index
• Subject Index