Monday, February 26, 2018

Abnormal Psychology & the DSM

Challenges in Defining “Normal”
A psychological disorder is a condition characterized by abnormal thoughts, feelings, and behaviors. However, defining what is “normal” and “abnormal” is a subject of much debate. Definitions of normality vary widely by person, time, place, culture, and situation. “Normal” is, after all, a subjective perception, and also an amorphous one—it is often easier to describe what is not normal than what is normal.

In simple terms, however, society at large often perceives or labels “normal” as “good,” and “abnormal” as “bad.” Being labeled as “normal” or “abnormal” can therefore have profound ramifications for an individual, such as exclusion or stigmatization by society.

Although it is difficult to define “normal,” it is still important to establish guidelines in order to be able to identify and help people who are suffering. To this end, the fields of psychology and psychiatry have developed the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), a standardized hierarchy of diagnostic criteria to help discriminate among normal and abnormal (i.e. “pathological”) behaviors and symptoms. The 5th edition of the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (the DSM-5) lays out explicit and specific guidelines for identifying and categorizing symptoms and diagnoses.(1)

Clinical Definitions of Abnormal: The DSM
The DSM is a central element of the debate around defining normality, and it continues to change and evolve. Currently, in the DSM-5 (the fifth edition), abnormal behavior is generally defined as behavior that violates a norm in society, is maladaptive, is rare given the context of the culture and environment, and is causing the person distress in their daily life. Specifically, the goal of the DSM-5 is to identify abnormal behavior that is indicative of some kind of psychological disorder. The DSM identifies the specific criteria used when diagnosing patients; it represents the industry standard for psychologists and psychiatrists, who often work together to diagnose and treat psychological disorders.(1)

What Is the DSM?
Although a number of classification systems have been developed over time for the diagnosis of mental disorders, the one that is used by most mental health professionals in the United States is the Diagnostic and Statistical Manual of Mental Disorders (DSM), published most recently in its 5th edition (known as the “DSM-5”) by the American Psychiatric Association in 2013.

The DSM is the standard classification manual of mental disorders and contains a hierarchy of diagnostic criteria for every mental-health disorder recognized by the American Psychiatric Association.

The DSM is often considered a “necessary evil”—it has many flaws, but it is also the only widely accepted method of diagnosing mental disorders.(1)

History of the DSM

The initial impetus for developing a classification of mental disorders in the United States was the need to collect statistical information. Research and changing cultural norms have contributed to the DSM’s evolution over time.

DSM-I (1952)
The first version of the DSM was created in response to the large-scale involvement of psychiatrists in the treatment, processing, and assessment of World War II soldiers. The DSM-I was 130 pages long and listed 106 mental disorders, many of which have since been abandoned.

DSM-II (1968)
The DSM-I and the DSM-II are clear reflections of the strongly psychodynamic slant the field of psychology had at the time of their publication. Symptoms were not specified in detail for specific disorders, and many were seen as reflections of broad underlying conflicts or maladaptive reactions to life problems, rooted in a distinction between neurosis and psychosis. Sociological and biological knowledge was incorporated in a model that did not emphasize a clear boundary between normality and abnormality.

DSM-III (1980)
Around this time, a controversy emerged regarding the deletion of the concept of neurosis. Faced with enormous political opposition, the DSM-III was in serious danger of not being approved by the American Psychological Association’s (APA’s) board of trustees unless “neurosis” was included in some capacity; a political compromise reinserted the term in parentheses after the word “disorder,” in some cases. The DSM-III included more than twice as many diagnoses (265) as the original DSM-1 and was nearly seven times its size (886 total pages).

DSM-IV (1994)
In this version, a clinical significance criterion was added to almost half of all the categories. This criterion required that symptoms cause “clinically significant distress or impairment in social, occupational, or other important areas of functioning.”

A “text revision” of the DSM-IV, known as the DSM-IV-TR, was published in 2000. The DSM-IV-TR was organized into a five-part axial system.
Axis I: Clinical disorders, such as depression and anxiety.
Axis II: Personality disorders and/or developmental disorders (such as intellectual disabilities, formerly called mental retardation).
Axis III: Physical issues that may impact mental health, such as diabetes.
Axis IV: Psychosocial stressors, such as occupational problems.
Axis V: A global assessment of functioning score (GAF), which provides a score of the person’s overall functioning from 1 to 100.

DSM-5 (2013)
Perhaps the most controversial version yet, the DSM-5 contains extensively revised diagnoses; it broadens diagnostic definitions in some cases while narrowing definitions in other cases. Notable changes include the change from autism and Asperger syndrome to a combined autism spectrum disorder; dropping the subtype classifications for variant forms of schizophrenia; dropping the “bereavement exclusion” for depressive disorders; a revised treatment and naming of gender -identity disorder to gender dysphoria; and changes to the criterion for post-traumatic stress disorder (PTSD). The DSM-5 has discarded the multiaxial system of diagnosis of the DSM-IV, listing all disorders on a single axis. It has replaced Axis IV with significant psychosocial and contextual features and dropped Axis V (the GAF) entirely. Although DSM-5 is longer than DSM-IV, the volume includes only 237 disorders, a decrease from the 297 disorders that were listed in DSM-IV.(1)

DSM-5 Disorders
The DSM-5 categorizes disorders into the following 20 chapters:(2)
  • Neurodevelopmental Disorders 
  • Schizophrenia Spectrum and Other Psychotic Disorders 
  • Bipolar and Related Disorders 
  • Depressive Disorders 
  • Anxiety Disorders 
  • Obsessive-Compulsive and Related Disorders 
  • Trauma- and Stressor-Related Disorders 
  • Dissociative Disorders 
  • Somatic Symptom Disorders 
  • Feeding and Eating Disorders 
  • Elimination Disorders 
  • Sleep-Wake Disorders 
  • Sexual Dysfunctions 
  • Gender Dysphoria 
  • Disruptive, Impulse Control and Conduct Disorders 
  • Substance Use and Addictive Disorders 
  • Neurocognitive Disorders 
  • Personality Disorders 
  • Paraphilic Disorders 
  • Other Disorders

(1) Lumen: Introduction to Abnormal Psychology
(2) American Psychiatric Association: The Organization of DSM-5

Psychopathology and Psychotherapy

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