Lecture 2 CLASSIFICATION Lecture Outline I. Introduction II. Historical Systems III.General Problems IV. The Diagnostic and Statistical Manuals A. DSM I B. DSM II C. DSM III D. DSM III-R V. General Classification Issues A. Natural Kinds B. Language VI. Diagnosis and Classification ------------------------------------------ I. Introduction We have discussed some of the issues involved in defining "abnormal behavior" per se. But clearly, "defining" does not stop there. Even the lay person is aware that there exist various types of abnormal behaviors. The task for the psychologist, then, is to specify what these different types are. Some classification system is necessary. Botanists would never have advanced their field without a clear taxonomy for classifying plants. Mere "Plant" - "Not Plant" distinctions would not be very fruitful! So, too, we need to have a system that allows us to identify the different types of disorders which fall under the rubric of "Abnormality". Importance of classification (see, for example, Blashfield & Draguns, 1976): A. Description - identification of presence of a disorder. B. Communication - need a vocabulary. C. Research - homogeneous groups. D. Treatment decisions - intervention, prognosis. E. Third-party reimbursement - insurance companies require a diagnosis. F. Funding for programs. G. Theory development. In striving for a classification system, a number of things have traditionally been sought (see, for example, Sprock & Blashfield, 1983): A. Exhaustive system: the classification system should account for all the types of abnormal behavior that we encounter. A classification system for plants would be of limited use if it had nothing to say about all the plants in your backyard. B. Mutually exclusive categories/Independent dimensions: Your plant classification system should clearly distinguish between plants, even those that are very similar. There should be no doubt which plant this plant is. Likewise, the most powerful classification system for mental disorders will not result in fuzzy categories and uncertainty over whether this person suffers from disorder A or disorder B. [Actually, not all classification systems rely on distinct categories - some base classification on determining where a person falls on various dimensions -all people falling somewhere on each of the dimensions (eg: some possible dimensions might be "emotionality" or "introversion"). These dimensions, however, must be independent. If two or more dimensions overlap, then they're not really measuring separate aspects of a person. Just like we wanted our categories to be separate, in this approach, the different dimensions need to be independent. We'll have more to say about this approach later in the course]. C. Reliability: Each time you use your classification system, it should give you the same result if you're classifying the same individual. If yesterday I classified this plant as a rose based on classification system X, then using the same system X, I (or anyone else) will today classify that same plant as a rose. A classification system that leads me to diagnose this person as schizophrenic today and depressed next week isn't very useful. [Note: Reliability suffers when conditions (A) and (B) above are not met]. D. Validity: Finally, a classification system should be saying something that is true about the "real world". If my classification system is supposed to be classifying mental disorders, than that is what it should do! If my system has categories such as schizophrenia, anxiety disorder, and depression, then there should actually exist these disorders. No matter how nice it would be to have the "Ronald Reagan Bush" in my plant classification system, a system with such a category would not be completely valid. In fact, a whole system might be invalid: My system categorizes people according to shoe size - those with sizes 0-3 are depressed, 4-7 are anxious, 8-10 are schizophrenic, 11-13 suffer from borderline personality disorder. Note, this is a very reliable system (shoe size can be measured very accurately), but it is totally invalid! II. Historical systems A. Probably began in ancient pre-history (indeed, probably even with pre-humans), when people first noticed differences in others and wanted to understand those differences. B. Ancient Greece: Hippocrates, fourth century B.C. Elaborated a medical model of madness, centering on the interactions of four bodily fluids ("humors") - blood, black bile, yellow bile, and phlegm - and devised a classification system based on the four corresponding temperaments - sanguine, melancholic, choleric, and phlegmatic . The specifics aren't important here (although make sure you review Hippocrates' theory as discussed in your text, pp. 31-32); what is important is that Hippocrates and his followers rejected the prevailing notion that illness was of divine or sacred origin. Thus, as physical illness could be classified, so too could mental illness. Hippocrates' approach, if not his actual theory, was the foundation for classification systems for centuries to come (Veith, 1957). C. Other developments: (Kaplan & Sadock, 1981; Veith, 1957). 1. Jean Fernel (1497-1588): An Anatomical Approach - related disease and body structure. First to use the word "physiology" in the modern sense, and coined the word "pathology". [Some modern researchers have followed in Fernel's footsteps. Sheldon (1954), for example, tied physical body "types" to personality characteristics. There is little evidence, however, to support this approach]. 2. Felix Platter (1536-1614): A new classification system of illnesses, based on symptomatology. 3. Late 17th Century: Physicians and neurologists engaged in a giant effort to create an all-encompassing taxonomic system, with irreducible and constant units. Hopes are high. 4. Francois Baussier de Sauvages (18th Century): developed a system based on his detailed observations. Consisted of 10 classes, 40 orders, 78 genera, 2,400 distinct diseases! The problem with this system is that it failed to differentiate between symptoms and diseases: "symptom" = an observable (physiological, psychological, etc) manifestation of a disease. "disease" = an impairment of the normal state of the organism, identified by the particular group of symptoms and a specific cause. 5. Philippe Pinel (1745-1826): French psychiatrist and a pupil of Sauvages. Developed the first workable psychiatric nosography. 5 forms of insanity: mania, melancholia with delirium, melancholia without delirium, dementia, idiotism. In this system, Pinel avoided physiological fictions and metaphysical hypotheses. His system was purely descriptive. 6. Emil Kraepelin (late 19th century): A student of Wilhelm Wundt, and the "father of systematic psychiatry" (Weckowicz, 1984). Kraepelin's goal was to devise an accurate definition of the separate disease processes and disease entities. He made a vast number of observations, collected case histories on hundreds of people, and eventually published his two volume, 2,425 page Lehrbuch. This book contains his medical classification scheme, the first truly comprehensive system. In it he defines two major groups of mental disorders: the manic- depressive psychoses, and dementia praecox (ie schizophrenia). These were further subdivided into 18 specific mental disorders. Kraepelin's system is important because it defined the discipline of psychiatry as distinct from neurology, and as a part of the general field of medicine. Kraepelin's influence is felt even in many modern classification systems. III. General problem with these classification systems A. Unreliable: Consistent diagnoses were difficult to obtain. In addition, specific characteristics of a disorder as described in the various classification systems were inconsistently associated with the disorder they were supposed to be associated with. B. Often theory laden: Often the only support for a particular classification system was theoretical - there was no actual evidence/data to support the system (or the theory!). In addition, the theory ladenness of these systems made it virtually impossible for practitioners of different theoretical persuasions to communicate with each other. As a result, some people argued that the ideal classification system should be theory-free and thereby useful to all. C. Overlapping categories: It was difficult to distinguish between one category and another - difficult to know where to "place" someone into the diagnostic system. D. Lack validity: There was little evidence that the nature of psychological disorders was accurately represented by these classification systems. IV. The Diagnostic and Statistical Manuals A. DSM-I: The American Psychiatric Association, in the 1950's, attempted to address these problems. In 1952 they published DSM-I, the next step in the evolution of psychiatric taxonomy. Nevertheless, it was still largely unreliable and some complained that it was too theory laden, especially with a psychodynamic view (APA, 1987). Note: It is not altogether clear why a classification should be (or even could be) theory-free...but more on this in the future. B. DSM-II: A goal of this 1968 revision was compatibility with the World Health Organization's International Classification of Diseases, 8th ed. (ICD-8) which covers all diseases and disorders, both physical and psychological, for the entire world (it, too, has since been revised and updated). The APA and WHO worked closely, consulting with each other to ensure compatibility. In addition, DSM-II attempted to use term that did not imply any particular theoretical framework. The goal was to be purely descriptive. C. DSM-III: But there were still problems with the second edition: continuing unreliability, still largely psychodynamic in orientation, incompatible or inconsistent with new research advances and new diagnostic methodologies (tests, interviews, etc.). The ICD was of little help - the ICD was not sufficiently detailed for clinical and research use in the U.S.. The APA was striving for a system that would be as clinically useful as possible to a wide range of professionals (APA, 1987). During the 70's, a number of efforts were made to address these problems. Attempts were made to be as atheoretical as possible and instead rely on purely descriptive terminology. As a result, reliability indeed improved with these new classification systems. In 1972, Feighner and his coworkers (Feighner, Robins, Guze, et al., 1972) published a classification system which established explicit definitions for 16 psychiatric disorders. There were clearly defined rules about which characteristics were necessary and how many were sufficient to make a particular diagnosis. Spitzer, Endicott, and Robins built on Feighner's work by adding criteria regarding the severity, duration, and course of specific disorders. Their work resulted (in 1978) in the publication of the Research Diagnostic Criteria (RDC), containing explicit diagnostic criteria for 25 diagnostic categories. Based on the work of people like Feighner and Spitzer, in 1980 the APA released the DSM-III. This was a "bold departure" from the previous DSM's (Smith & Kraft, 1982). The DSM-III has a number of important characteristics (APA, 1980): 1. Descriptive approach, largely because etiology is typically unknown, debatable, or theory laden. Thus, DSM-III strives to be atheoretical, using merely observationally referent terms. The hope with this is to make the manual as acceptable as possible to professionals with different theoretical orientations. 2. Specific criteria for making diagnoses (not provided in I, II, or the ICD). 3. Systematic description: the DSM-III provides information on essential features, associated features, prevalence rates, sex ratios, family patterns, and differential diagnoses (ie: possible alternative or additional diagnoses that should be considered). 4. Multiaxial system: this is the major advance over II. The multiaxial approach (to be described below) allows for a more holistic and comprehensive account of an individual (Smith & Kraft, 1983). D. DSM-III-R: In 1987, the APA published a revised version of DSM- III. The goals of this revision (APA, 1987) were: 1. expanded coverage 2. increased reliability (a major complaint with the 3rd edition was the unreliability of the personality disorders) 3. updated with the latest research findings Note: It is very difficult to do both 1 and 2 at the same time. The more coverage a system has, the more possibility for differing diagnoses, and hence unreliability. On the other hand, the fewer the number of categories, the higher will be a system's reliability, but the increased likelihood that individuals will not fit perfectly into any particular category. The goal of DSM-III-R is to avoid such mixed or atypical diagnoses, while at the same time have good coverage and reliability (Morey, 1988). Thus, the revised manual contain over 100 changes in its diagnostic criteria (Peele, 1986), and also changes in its multiaxial system of diagnosis. DSM-III-R Multiaxial System A person is assessed on several different axes or dimensions, each focusing on a different type of information. Axis I Clinical Syndromes Axis II Developmental disorders and Personality disorders Axis III Physical disorders and conditions Axis IV Severity of psychosocial stressors Axis V Global assessment of functioning I and II comprise the entire classification of mental disorders, plus "V codes" (codes which indicate conditions not attributable to a mental disorder but that are a focus of attention or treatment. Eg: Academic, interpersonal or occupational problems). I, II and III together constitute the official, complete DSM-III-R diagnostic assessment. I: Clinical syndromes: Florid psychological disorders, such as major depression or panic disorder. II: Developmental and Personality disorders: Pervasive, long standing disorders, typically beginning in childhood or adolescence. Eg: Mental retardation or borderline personality disorder. A person can have a diagnosis on both axis I and II. III: Physical disorders/conditions: Current physical complaints that may be relevant to understanding or managing the case. Eg: Neurologic disorders or diabetes. IV: Severity of psychosocial stressors: Overall severity of life stress for the past year. (Stress is clearly related to mental health, including the development, recurrence, and exacerbation of a disorder). Types of stressors: marital financial parenting legal interpersonal phases of the life cycle occupational physical illness/injury living circumstances disasters, rape, persecution... These stressors are rated on a six point scale, ranging from "None" to "Catastrophic". V. Global Assessment of functioning: This allows the clinician to give his/her judgment of the person's psychological, social and occupational functioning for two time periods: 1. Current: reflects need for treatment 2. Past Year-highest level of functioning: reflects possible prognosis Each is rated on a 90 point scale, ranging from 1 (Suicidal acts, recurrent violence, etc) to 90 (Absent or minimal symptoms). [Note: In the DSM-III system, Axis V referred to "Highest Level of Adaptive Functioning Past Year" - social and occupational functioning for the past year only. The DSM-III- R expands this to include social, occupational as well as psychological functioning for both the past year and the present. In addition, the DSM-III rated functioning on just a 7 point scale ("superior" to "grossly impaired")]. V. General Classification Issues A. Natural kinds: The assumption behind diagnostic systems like DSM-III-R is that illness is a "thing in itself" (Veith, 1957) - that each disorder is a distinct entity. But are there "natural kinds"? That is, are there actually disorders that truly exist "out there" in the world. Or are the disorders as defined in the DSM-III-R simply figments of scientists' imaginations! We're talking about "reality" (what ever that is!) -and whether or not the DSM-III-R has accurately "cut it up". The DSM is assuming that the disorders it defines are real and accurately defined. There is a controversy, to which we will return to in detail later in the course, over whether the various mental illnesses (however defined: by the DSM-III-R or by any other system) are social constructions rather than actual "things" (cf Wartofsky, 1983: "childhood" as a cultural invention). That is, schizophrenia, for example, doesn't really exist as a real disease (the way, say, diabetes is real), but is at best a hypothetical entity which happens to help us organize and simplify our thinking about some complex human behavior (Suppe, 1977). Some have gone so far as to claim that mental illness is entirely a myth - that there is no such thing at all and it is actually harmful to think that there is (Sharman, 1970; Szasz, 1961). But, again, more on this later in the course. At this point, I just want you to get your "critical caps" placed firmly on your heads - We'll be talking about all sorts of disorders in this course (schizophrenia, major depression, agoraphobia...), but how do we know what these things really are? Do they exist? How do we define them? Is there a better way to think about abnormal behavior? How would you know it's a better way? B. Inadequate language of description (Rotter, 1954): Our terms, even purely descriptive ones, have too many referents (ie: a single word can refer to many different things, depending on how it is used), unclear referents, or nonspecific referents. This can lead to Fuzziness: Words used in clinical psychology are often vague. Intelligence, Frustration, Anxiety and Depression, for example, have no clear referents. These terms can also have elastic meaning depending on one's perspective. So, it's difficult to know with precision what we are talking about! When I say "anxiety", what precisely do you hear or understand? Do each of you think of exactly the same thing? Unlikely. C. Reification: A particularly difficult problem is the problem of reification. The words we use to describe people, such as "anxious", "depressed", and so on were meant for just that: to describe them. However, there is the danger that those terms will be turned around to explain people's behavior: "Why does she act that way?" "Because she is depressed". The description becomes the explanation - a circular and thus meaningless explanation is set up. The description is used to explain itself! Unfortunately, this is a very common problem, not just with our everyday thinking, but also in scientific thinking. Let's keep our eyes open for it! The DSM-III-R tries to address at least the "fuzziness" issue. Whatever its shortcomings, it is important to understand that the DSM "freezes in time `one still frame' in the area of study that is constantly advancing" (Smith & Kraft, 1983). VI. A note on Diagnosis and Classification Classification is a central aspect of the overall diagnostic process (Cooper, 1983). Diagnostic process: 1. Decisions about what data to collect. 2. Data collection - interviews, tests, observations of behavior. 3. Sort data and select aspects of it to make inferences and decisions regarding symptoms, traits, disabilities, skill deficits, etc. 4. Summarization of this potentially diagnostic information. 5. Use information to place client into a particular classification (ie: give a diagnosis). The diagnostic process is itself an aspect of the final clinical formulation or assessment. This will include: diagnosis, history, current situation, interpersonal and social context. The diagnosis is a general indicator of the type of problem(s) to be expected, the tendency toward certain behavioral and emotional patterns.