Psychopathology

History, Diagnosis, and Empirical Foundations

W. Edward Craighead, David J. Miklowitz, Linda W. Craighead, W. Edward Craighead, David J. Miklowitz, Linda W. Craighead

• Publisher: Wiley
• Year: 2017
• ISBN:
  9781119221753
• Edition: 3
• Topic: Psychology
• Subtopic: Psychopathology
• Index: Psychology

A modern take on adult disorders, incorporating context, research, and more

Psychopathology provides unique, state-of-the-art coverage of adult psychopathology as categorical, evidence-based, and continuously evolving. Comprehensive coverage features a detailed examination of DSM disorders, including description, epidemiology, prevalence, consequences, neurobiological and translational research, treatment, and more, with each chapter written by an experts in the field. Mapped to the DSM-5, each chapter includes clinical case examples that illustrate how psychopathology and assessment influence treatment. This new third edition has been updated to align with the latest thinking on alcohol and substance use disorders, sleep-wake disorders, and personality disorders. Students will delve into the DSM system's limitations and strengths, and they will gain deeper insight into the historical context in which today's diagnoses are made.

Advancing research continues to broaden the boundaries of psychopathology beyond traditional lines, revealing its complexity while simultaneously deepening our understanding of these disorders and how to treat them. This book goes beyond DSM descriptions to provide a comprehensive look at the whole disorder, from assessment through treatment and beyond.

• Review DSM-5 classifications matched with illustrative case examples
• Learn the neurobiological and genetic factors related to each disorder
• Understand related behavioral, social, cognitive, and emotional effects
• Delve into translational research, assessment methodologies, and treatment

Contributions from specialists in each disorder provide exceptional insight into all aspects of theory and clinical care. Psychopathology helps students see the whole disorder—and the whole patient.

Chapter 1
Diagnosis
Conceptual Issues and Controversies

Scott O. Lilienfeld Sarah Francis Smith Ashley L. Watts

Psychiatric diagnosis is fundamental to the understanding of mental illness. Without it, the study, assessment, and treatment of psychopathology would be in disarray. In this chapter, we examine (a) the raison d'être underlying psychiatric diagnosis, (b) widespread misconceptions regarding psychiatric classification and diagnosis, (c) the present system of psychiatric classification and its strengths and weaknesses, and (d) fruitful directions for improving this system.

A myriad of forms of abnormality are housed under the exceedingly broad umbrella of mental disorders. Indeed, the current psychiatric classification system, as described in the Diagnostic and Statistical Manual of Mental Disorders (DSM‐5), contains well over 300 diagnoses (American Psychiatric Association [APA], 2013). In addition, Chapter V of the International Classification of Diseases, 10th edition (ICD‐10), contains approximately 100 diagnoses housed within 26 categories (World Health Organization, 1992). The enormous heterogeneity of psychopathology makes a formal system of organization imperative. Just as in the biological sciences, where Linnaeus's hierarchical taxonomy categorizes fauna and flora, and in chemistry, where Mendeleev's periodic table orders the elements, a psychiatric classification system helps to organize the bewildering subforms of abnormality. Such a system, if effective, permits us to parse the variegated universe of psychological disorders into more homogeneous, and ideally more clinically meaningful, categories.

From the practitioner's initial inchoate impression that a patient's behavior is aberrant to his or her later and better‐elaborated case conceptualization, diagnosis plays an integral role in the clinical process. Indeed, the essential reason for initiating assessment and treatment is often the observer's sense that “something is just not quite right” about the person. Meehl (1973) commented that the mental health professional's core task is to answer the question: “What does this person have, or what befell him, that makes him different from those who have not developed clinical psychopathology?” (p. 248). Therein lies the basis for psychiatric diagnosis.

General Terminological Issues

Before proceeding, a bit of terminology is in order. It is crucial at the outset to distinguish two frequently confused terms: classification and diagnosis. A system of classification is an overarching taxonomy of mental illness, whereas diagnosis is the act of placing an individual, based on a constellation of signs (observable indicators, like crying in a depressed patient) or symptoms (subjective indicators, like feelings of guilt in a depressed patient), or both, into a category within that taxonomy. Classification is a prerequisite for diagnosis.

Another key set of terminological issues concerns the distinctions among syndrome, disorder, and disease. As Kazdin (1983) observed, we can differentiate among these three concepts based on our levels of understanding of their pathology—the underlying pathophysiology that may accompany the condition—and etiology, that is, causation (Gough, 1971; Lilienfeld, Waldman, & Israel, 1994).

At the lowest rung of the hierarchy of understanding there are syndromes, which are typically constellations of signs and symptoms that co‐occur across individuals (syndrome means “running together” in Greek). In classical syndromes, neither pathology nor etiology is well understood, nor is the syndrome's causal relation to other conditions established. Antisocial personality disorder is a relatively clear example of a syndrome because its signs (e.g., the use of an alias) and symptoms (e.g., lack of remorse) tend to covary across individuals. Nevertheless, its pathology and etiology are largely unknown, and its causal relation to other conditions is poorly understood (Lykken, 1995). In contrast, some authors (e.g., Lilienfeld, 2013; but see Lynam & Miller, 2012) argue that psychopathic personality (psychopathy) may not be a classical syndrome. These researchers contend that psychopathy is instead a configuration of several largely independent constructs, such as boldness, coldness, and disinhibition, that come together in an interpersonally malignant fashion (Patrick, Fowles, & Krueger, 2009; see also Vitale & Newman, Chapter 15, in this book).

In other cases, syndromes may also constitute groupings of signs and symptoms that exhibit minimal covariation across individuals but that point to an underlying etiology (Lilienfeld et al., 1994). For example, Gerstmann's syndrome in neurology (Benton, 1992) is marked by four major features: agraphia (inability to write), acalculia (inability to perform mental computation), finger agnosia (inability to differentiate among fingers on the hand), and left‐right disorientation. Although these indicators are negligibly correlated across individuals in the general population, they co‐occur dependably following certain instances of parietal lobe damage.

At the second rung of the hierarchy of understanding there are disorders, which are syndromes that cannot be readily explained by other conditions. For example, in the present diagnostic system, obsessive‐compulsive disorder (OCD) can be diagnosed only if its symptoms (e.g., recurrent fears of contamination) and signs (e.g., recurrent hand washing) cannot be accounted for by a specific phobia (e.g., irrational fear of dirt). Once we rule out other potential causes of OCD symptoms, such as specific phobia, anorexia nervosa, and trichotillomania (compulsive hair pulling), we can be reasonably certain that an individual exhibiting marked obsessions or compulsions, or both, suffers from a well‐defined disorder (APA, 2000, p. 463).

At the third and highest rung of the hierarchy of understanding there are diseases, which are disorders in which pathology and etiology are reasonably well understood (Kazdin, 1983; McHugh & Slavney, 1998). Sickle‐cell anemia is a prototypical disease because its pathology (crescent‐shaped erythrocytes containing hemoglobin S) and etiology (two autosomal recessive alleles) have been conclusively identified (Sutton, 1980). For other conditions that approach the status of bona fide diseases, such as Alzheimer's disease, the primary pathology (senile plaques, neurofibrillary tangles, and granulovacuolar degeneration) has been identified, while their etiology is evolving but incomplete (Selkoe, 1992).

With the possible exception of Alzheimer's disease and a handful of other organic conditions, the diagnoses in our present system of psychiatric classifications are almost exclusively syndromes or, in rare cases, disorders (Kendell & Jablensky, 2003). This fact is a sobering reminder that the pathology in most cases of psychopathology is largely unknown, and their etiology is poorly understood (Kendler, 2005; Kendler, Zachar, & Craver, 2011). Therefore, although we genuflect to hallowed tradition in this chapter by referring to the major entities within the current psychiatric classification system as mental “disorders,” readers should bear in mind that few are disorders in the strict sense of the term.

Functions of Psychiatric Diagnosis

Diagnosis serves three principal functions for practitioners and researchers alike. We discuss each in turn.

Diagnosis as Communication

Diagnosis furnishes a convenient vehicle for communication about an individual's condition. It allows professionals to be reasonably confident that when they use a diagnosis (such as persistent depressive disorder or borderline personality disorder) to describe a patient, other professionals will recognize it as referring to the same condition. Moreover, a diagnosis distills relevant information, such as frantic efforts to avoid abandonment and chronic feelings of emptiness, in a shorthand form that aids in other professionals' understanding of a case. Blashfield and Burgess (2007) described this role as “information retrieval.” Just as botanists use the name of a species to summarize distinctive features of a specific plant, psychologists and psychiatrists rely on a diagnosis to summarize distinctive features of a specific mental disorder (Blashfield & Burgess, 2007). Diagnoses succinctly convey important information about a patient to clinicians, investigators, family members, managed care organizations, and others.

Establishing Linkages With Other Diagnoses

Psychiatric diagnoses are organized within the overarching nosological structure of other diagnoses. Nosology is the branch of science that deals with the systematic classification of diseases. Within this system, most diagnostic categories are arranged in relation to other conditions; the nearer in the network two conditions are, the more closely related they ostensibly are as disorders. For example, social anxiety disorder (social phobia) and specific phobia are both classified as anxiety disorders in the Diagnostic and Statistical Manual of Mental Disorders (DSM‐5; APA, 2013), and are presumably more closely linked etiologically than are social anxiety disorder and narcissistic personality disorder, the latter of which is classified as a personality disorder in DSM‐5. Thus, diagnoses help to locate the patient's presenting problems within the context of both more and less related diagnostic categories.

Provision of Surplus Information

Perhaps most important, a diagnosis helps us to learn new things; it affords us surplus information that we did not have previously. Among other things, a diagnosis allows us to ...