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
      
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      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.