Psychopathology and Psychotherapy

DSM-5 Diagnosis, Case Conceptualization, and Treatment

Len Sperry, Jon Sperry, Jon Carlson, Jill Duba Sauerheber, Len Sperry, Jon Carlson, Jill Duba Sauerheber, Jon Sperry

• Publisher: Routledge
• Year: 2014
• ISBN:
  9781135038540
• Edition: 3
• Topic: Psychology
• Subtopic: Psychopathology
• Index: Psychology

Psychopathology & Psychotherapy: DSM-5 Diagnosis, Case Conceptualization, and Treatment, Third Edition differs from other psychopathology and abnormal psychology books. While other books focus on describing diagnostic conditions, this book focus on the critical link between psychopathology and psychotherapy. More specifically, it links diagnostic evaluation, case conceptualization, and treatment selection to psychotherapy practice. Research affirms that knowledge and awareness of these links is essential in planning and providing highly effective psychotherapy.

This third edition incorporates detailed case conceptualizations and treatment considerations for the DSM-5 diagnoses most commonly seen in everyday clinical practice. Extensive case studies illustrate the diagnostic, case conceptualization, and treatment process in a way that makes it come alive. Written by practicing clinicians with expertise in specific disorders, this book will be an invaluable resource to both novice and experienced clinicians.

1 Diagnosis, Case Conceptualization, Culture, and Treatment

Len Sperry

A 31-year-old married female presents for therapy with depression and a fear of seriously harming her younger son. What more would you want to know about her? What is your diagnostic impression and case conceptualization? What are your treatment recommendations? Alfred Adler dealt with such questions with a similar client when he consulted on Mrs. A., his most famous case. The Case of Mrs. A. is a great way to begin a discussion of the Adlerian Psychology perspective on psychopathology and psychotherapy.

Certainly, much more is known about the process of normal development and psychopathology than in 1931 when Adler’s consultation took place. Similarly, the hope is greater that treatment interventions can more effectively reduce and even reverse psychopathological processes than in past decades. This chapter has three purposes: First, it describes Alfred Adler’s basic view of normality and psychopathology, along with some observations that extend and clarify it. Second, it overviews some of the basic changes in the use of the new Diagnostic and Statistical Manual, Fifth Edition (DSM-5) (American Psychiatric Association, 2013). Next, it compares the atheoretical DSM-5 with Adlerian Psychology theory and suggests how diagnostic considerations can be linked to treatment interventions. Because of the increasing importance of cultural factors in clinical practice today, their place in a case conceptualization is noted. Finally, there is an analysis of the Case of Mrs. A., with DSM-5 diagnoses and an Adlerian case conceptualization.

Alfred Adler’s View

Alfred Adler was the founder of the psychological theory and system called Individual Psychology (Adler, 1956). Adler chose the term “Individual”—as its Latin derivation meant “indivisible”—referring to the essential unity of the person. Adler believed that the hallmark of the healthy, nonpathological person was the capacity to move through life meeting the various life tasks with courage and common sense. Adler called this hallmark “social interest.” In no way did Adler imply that such an individual was perfect or fully self-actualized. Actually, healthy persons can use private logic, experience some discouragement and a sense of inferiority, for which they compensate in ways that are outside the reaches of social interest. The common perception is that imperfections and failures are part of the human condition. On the other hand, pathological persons believe that they must be perfect, and then justify their thinking and actions as the only way to achieve perfection. For Adler, all personality dysfunction was the outcome of erroneous conceptions of how to achieve personal superiority. For the most part, he believed that these faulty conceptions were formed early in one’s life (Adler, 1956).

A neurotic disposition, Adler’s term for the predisposing conditions that can result in psychopathology, stems from childhood experiences that are characterized either by overprotection or neglect, or by an admixture of both. From these experiences, the young child develops a set of psychological convictions—about self, the world and life goal, which becomes the life style—of his/her inability to develop mastery or cope with the tasks of life. These convictions are confounded and reinforced by the child’s perception of a hostile, punishing, or depriving environment at home or school, or one that is subtly demanding or frustrating. Rather than providing encouragement to engage in other efforts involving mastery and achievement, these experiences leave the youngster feeling discouraged and fearful. Rather than experiencing trusting and loving relationships, the young child grows to become distrustful and manipulative. To compensate for these exaggerated feelings of insecurity and anxiety, the child becomes self-centered and uncooperative.

So what is a pathological or dysfunctional life style? The dysfunctional life style is an inflexible life style. In it, problem-solving is based upon a self-protective “private sense,” rather than a more task-oriented and socially useful “common sense.” Once this set of faulty psychological convictions has coalesced and self-protective patterns of coping are established, the individual has difficulty in seeing or responding to life in any other way. The end result is that an individual with such a style cannot productively cope with the tasks of life nor really enjoy the rewards of his/her labors, much less his/her relationships with others. In contrast, a set of psychological convictions and coping patterns that are shaped positively by the child’s healthy experiences of mastery, creativity, and loving and pleasurable relationships will result in a flexible life style.

Adler presented a unitary theory of psychopathology, wherein the individual “arranges” symptoms uniquely to serve as excuses for not meeting the tasks of life or to safeguard self-esteem either by aggression or distancing from others (Carlson, Watts, & Maniacci, 2006).

Adler discriminated dysfunctional behavior along the dimensions of social interest and degree of activity. For instance, neurotics respond to the life tasks with “Yes—but.” With the “yes,” the individual acknowledges social responsibilities, and with the “but,” symptoms are presented which excuse responsibility. Mosak (1984) described two types of “yes—but” responses: “Yes—but I’m sick,” which is the classic response of the psychoneurotic; and, “Yes—but I defy it,” the acting-out response of the character neurosis or personality disorder. On the other hand, psychotics respond to life tasks with “No,” and cut themselves off from the common world. As to activity level, Adler noted a low degree is found in neurotic conditions such as depression and obsessive-compulsion, with a higher degree in anxiety neurosis, Schizophrenia, and alcoholics. The highest levels were in manics and sociopaths (Adler, 1964a).

Developments in the Adlerian View

Adler believed that three main components were common to all psychopathology: discouragement, faulty conceptions, and life-style beliefs (Carlson, Watts, & Maniacci, 2006). Furthermore, he posited that undeveloped social interest and personality dysfunction were basically the outcome of an erroneous way of living. This represents Adler’s views of normality versus abnormality at the time of his death. It should be noted that at the outset of his career, Adler believed that psychopathology stemmed from various organ inferiorities. This was a rather biological and reductionistic position. Later, his view changed to a more intrapsychic view in which dysfunctional behavior was seen as a conflict between inferiority and superiority feelings. He described the “neurotic disposition” as the predisposing factor in the development of neurosis. The term “pampered life style” eventually replaced this term. Still later, Adler developed a more sociopsychological view in which psychopathology represented movement toward self-importance at the expense of the common good. In many respects, the last version of Adler’s theory represented one of the first attempts at developing a holistic view of psychopathology (Adler, 1964b). Although it encompassed features from the biological (organ inferiority and organ dialect) and the social realms, it was primarily a theory of emotional development and dysfunction, which integrated all processes through the prism of the life style: “This is notably the case with the lungs, the heart, the stomach, the organs of excretion and the sexual organs. The disturbance of these functions expresses the direction that an individual is taking to attain his goal. I have called these disturbances the organ dialect, or organ jargon, since the organs are revealing in their own most expressive language the intention of the individual totality” (Adler, 1964b, p. 156).

Neufield (1954) differentiated the early psychosomatic approaches from the biopsychosocial and integrative approaches like Individual Psychology. Most psychosomatic theories failed to fully appreciate the multi-faceted dynamics and interdependence of all of the biological, the psychological, and the social dimensions of human existence. Failure to appreciate all of these multi-faceted dimensions leads to the same narrow reductionism Neufield criticized in many early psychosomatic theories.

A tendency among those espousing an integrative theory has been to downplay some of these multi-faceted dynamics, particularly the biochemical and neuropharmacological ones. This is particularly true in the treatment of depressive disorders. A growing awareness is that depression is not a single entity but rather a spectrum disorder. As such, depression is currently viewed by many as a group of discrete illnesses that span a biopsychosocial continuum in which symptom patterns appear to be more influenced by biochemical factors at one end of the continuum and more by psychological factors at the other end (Sperry & Sperry, 2012). To illustrate the biopsychosocial perspective, a helpful procedure is to speculate about how a depressive disorder develops.

Based on recent research findings we can speculate that individuals who experience a Major Depressive Episode are in some ways genetically susceptible to depression, such that brain pathways and circuits dealing with emotions such as pleasure are fragile and poorly buffered from external influences. Add to this some early life traumas such as the loss or separation from a significant other—for instance a parent—that undermines selfconfidence and esteem, and for which individuals respond with safeguarding patterns. Subjecting individuals to a severe psychological stressor at a later point in life is interpreted by them as a threat that in some way echoes their early experience of loss or separation. When existing social support systems and personal coping strategies or safeguarding methods are not sufficient to neutralize this stressor, the already compromised brain biochemistry is overtaxed, resulting in the familiar biological symptoms of depression such as sleep and appetite disturbance, psychomotor retardation, reduced energy, inability to experience pleasure, and somatic symptoms such as constipation and headache. This reduced physiological functioning serves to further reinforce the individuals’ life-style beliefs about self, the world, and the future (Sperry, 2010; Sperry & Sperry, 2012).

Pancner (1985) suggested a similar hypothesis. On the other hand, Persistent Depressive Disorder (Dysthymia), previously called Dysthymia or Neurotic Depression, probably has more psychosocial loading than Major Depressive Disorder, which has more genetic and biological loading. Disorders like Persistent Depressive Disorder most often present with few biological symptoms and more dysfunctional life-style beliefs and coping skills. Thus, it is not surprising that such a disorder responds well to psychosocial therapies, while Major Depressive Disorder is more likely to respond to biochemical therapies such as antidepressant medications, often in conjunction with psychotherapy. Psychotherapy will be a necessary adjunctive treatment, assuming that a pampered life style or neurotic disposition interferes with functioning in life tasks. But, when little or no life-task dysfunction exists, as is sometimes the situation, then psychotherapy is less likely to be useful.

Case Conceptualization: Diagnostic, Clinical, Cultural, and Treatment Formulations

A case conceptualization is a way of summarizing diverse information in a brief, coherent manner for the purpose of better understanding and treating of the individual. Furthermore, a case conceptualization consists of four components: diagnostic formulations, clinical formulations, cultural formulation, and treatment formulations (Sperry, 2010; Sperry & Sperry, 2012).

A diagnostic formulation is a descriptive statement about the nature and severity of the individual’s psychiatric presentation. The diagnostic formulation aids the clinician in reaching three sets of diagnostic conclusions: whether the patient’s presentation is primarily psychotic, characterological, or neurotic; whether the patient’s presentation is primarily organic or psychogenic in etiology; and, whether the patient’s presentation is so acute and severe that it requires immediate intervention. In short, diagnostic formulations are descriptive, phenomenological, and cross-sectional in nature. They answer the “What happened?” question. For all practical purposes the diagnostic formulation lends itself to being specified with DSM-5 criteria and nosology.

A clinical formulation, on the other hand, is more explanatory and longitudinal in nature, and attempts to offer a rationale for the development and maintenance of symptoms and dysfunctional life patterns. Clinical formulations answer the “Why did it happen?” question. Just as various theories of human behavior exist, so do various types of clinical formulations exist: psychoanalytic, Adlerian, cognitive, behavioral, biological, family systems, biopsychosocial, or some combination. In this book, a combination of the Adlerian and biopsychosocial case conceptualizations is emphasized. In the following chapters it is designated as “Biopsychosocial-Adlerian Conceptualization.”

A cultural formulation is a systematic review and explanation of cultural factors and dynamics that are operative in the presenting problems. It answers the “What role does culture play?” question. More specifically, it describes the client’s cultural identity and level of acculturation. It provides a cultural explanation of the client’s condition, as well as the impact of cultural factors on the client’s personality and level of functioning. Furthermore, it addresses cultural elements that may impact the relationship between the individual and the therapist, and whether cultural or culturally sensitive interventions are indicated.

A treatment formulation follows from the diagnostic, clinical, and cultural formulations and serves as an explicit blueprint governing treatment interventions. Rather than answering the “What happened?” or “Why did it happen?” questions, the treatment formulation addresses the “What can be done about it, and how?” question.

The most useful and comprehensive case conceptualizations are integrative ones that encompass all four components: diagnostic, clinical, cultural, and treatment formulations (Sperry & Sperry, 2012; Sperry & Carlson, 2014). The format of the following chapters of this book will highlight integrative conceptualizations. The diagnostic formulation will emphasize DSM-5 criteria. The clinical formulation will emphasis Adlerian interpretations and dynamics, while the treatment formulation will suggest treatment goals and methods. Because DSM-5 is often incorporated into case conceptualizations today, the connection between DSM-5 and Adlerian dynamics will be evident throughout this book. Chapter 2 describes and illustrates how to develop Adlerian case conceptualizations.

Changes in DSM-5

The DSM diagnostic system has undergone some major changes since the second edition of this book was published in 1996. Most of these changes have involved adding or removing diagnoses and criteria. These will be described in subsequent chapters. However, there are also some major changes in the structure of the DSM-5 (American Psychiatric Association, 2013), and these are briefly noted here.

Single-Axis Diagnoses

The most obvious change in DSM-5 is the return to a single-axis diagnosis as it was in DSM-I and DSM-II. The multiaxial (5-axes) system was introduced in DSM-III and continued through DSM-IV-TR. Axis I was for coding clinical disorders and V codes, while Axis II was for coding personal...