Discussion
Bwortham
ContentServer.pdf
75
Amanda S. Cherry, Noel J. Jacobs, Timothy S. Thornberry Jr., and Stephen R. Gillaspy
Psychopathology and Use of the Diagnostic and Statistical Manual of
Mental Disorders
5
he purpose of this chapter is to provide a brief summary and review of diagnostic terms that you may encounter in your courses and as you read patient files during your practi- cum experiences. We start with a brief history of diagnostic systems and then proceed to a review of the Diagnostic and Statistical Manual of Mental Disorders (DSM), which is intended to provide a quick reference to general diagnostic criteria so that you will be able to better understand the diagnosed disorders of the patients with whom you come into contact. Additionally, this overview will assist you in understanding the criteria patients meet to reach a diagnosis for various disorders. Finally, the conclusion of the chapter allows you to test your clinical judgment with two case vignettes.
T
http://dx.doi.org/10.1037/14672-005 Your Practicum in Psychology: A Guide for Maximizing Knowledge and Competence, Second Edition, J. R. Matthews and C. E. Walker (Editors) Copyright © 2015 by the American Psychological Association. All rights reserved.
Co py
ri gh
t Am
er ic
an P sy
ch ol og ic al A ss oc ia ti on . No t fo r fu
rt he
r di
st ri
bu ti
on .
76 C h e r r y e t a l .
Diagnostic Systems— A History
Appropriate classifications and diagnoses are imperative for understand- ing patients, stimulating research, providing guidelines for empirically supported treatments, and obtaining reimbursement for services. One of the first documented attempts in classification of mental disorders was the 1840 census, which included one single category of “idiocy/ insanity.” This was then expanded to seven categories for the 1880 census: mania, melancholia, monomania, paresis, dementia, dipsomania, and epilepsy (American Psychiatric Association, 2014a). However, one of the earliest guides for diagnoses, Statistical Manual for the Use of Institutions for the Insane, was developed in 1917 by the “Committee on Statistics,” which was formed from the National Commission on Mental Hygiene and a group now known as the American Psychiatric Association (Grob, 1991). During World War II, there was a major shift in the role of psychi- atrist from mental institutions to assessing and treating soldiers. During this period of war, the Medical 203 was developed as a classification sys- tem issued as a “War Department Technical Bulletin” under the Auspices of the Surgeon General (Houts, 2000). The committee involved in the development of the Medical 203 was chaired by a brigadier general and psychiatrist, William C. Menninger. In addition to chairing this commit- tee, Menninger led a group of his colleagues in forming the Group for Advancement of Psychiatry (Houts, 2000). The means to classify mental health disorders further evolved in 1949 when the World Health Organization (WHO) published the sixth edition of the International Statistical Classification of Diseases (ICD–6; 2010), which included for the first time a section on mental disorders (American Psychiatric Association, 2014a). However, the ICD–6 was designed for international application, and therefore after this event an American Psychiatric Association com- mittee was empowered to develop a version specific to the United States as well as to standardize a system for classification. Thus, in 1950, the committee undertook the process of reviewing and consulting to compile the DSM. The initial version of the DSM (DSM–I) was approved in 1951 and published in 1952. Since that time, the DSM has undergone a process of evolution with each edition.
DSM–I contained 106 diagnostic categories. This initial edition was not well received because of its subjective nature. Therefore, the DSM–II, released in 1968, had the aim of diagnostic accuracy and shifted to a more distinct disease model. The major criticism of the second edi- tion was the DSM’s dehumanization of patients because it was viewed as treating conditions and not individuals. Then the DSM–III, released in 1980, was geared toward improving epidemiological accuracy and
Co py
ri gh
t Am
er ic
an P sy
ch ol og ic al A ss oc ia ti on . No t fo r fu
rt he
r di
st ri
bu ti
on .
77Psychopathology and Use of the Diagnostic and Statistical Manual
diagnostic validity, which became a guideline for insurance and reimbursement for services. With the revised third edition, classifi- cations of disorders were given to correspond with diagnostic coding of the WHO’s ICD, which is the official medical coding system used within the United States. The DSM–IV (American Psychiatric Associa- tion, 1994) and DSM–IV–Text Revision (American Psychiatric Associa- tion, 2000) continued to evolve with responses to epidemiology and cultural diversity, as well as continue to correspond with the ICD codes.
As the authors of the DSM–IV attempted previously, the authors of the DSM–5 have designed the book to give the clinician a conceptual guide and a tool book for greater understanding and practical applica- tion. Their goal in this new edition is to synthesize the latest medical and behavioral research with the existing understanding of mental dis- orders as it has been applied to clinical, pharmaceutical, legal, and social work with individuals. As research and clinical practice have evolved over time, new understandings (and new questions) have led to suc- cessive editions of this manual seen by many as the “bible” of mental health. However, the authors of each new edition try to make changes that improve not just the utility of the manual itself but also the under- standing of mental illness as a whole. This edition was organized as a parallel diagnostic code manual to the medical diagnostic manual titled the International Classification of Diseases, 10th Revision (ICD–10). Addi- tionally, the authors of the DSM–5 have reorganized the groupings of disorders and redefined and renamed other disorders in new ways to “stimulate new clinical perspectives” (American Psychiatric Associa- tion, 2013, p. xli). You will find, if you are somewhat versed in the categories and disorder descriptions of the DSM–IV already, that the new manual attempts to give more explicit consideration, even when brief, to developmental experience, cultural influence, and risk factors in the development and expression of emotional and behavioral diffi- culties. One of the most obvious differences you will notice between the previous and current editions is the elimination of the “axes” (used to differentiate primary psychological disorders from mental retardation, personality disorders, and primary health diagnoses) into a combined, nonaxial list followed by a designation of important contextual or inter- personal aspects of the difficulties that the patient is facing.
The DSM has undergone revisions into four editions since World War II and has become a standard classification system used by psychia- trists, other physicians, and mental health providers. It describes the essential features and full range of mental health disorders. The most current version, the DSM–5, was released in May 2013. The current ver- sion, like its predecessors, has been challenged to appropriately define and classify mental disorders.
Although this chapter focuses on DSM–5 definitions of mental health disorders, one should be aware that other classification systems
Co py
ri gh
t Am
er ic
an P sy
ch ol og ic al A ss oc ia ti on . No t fo r fu
rt he
r di
st ri
bu ti
on .
78 C h e r r y e t a l .
exist that will likely have a growing impact on psychological practice, conceptualization, and research. Along with DSM–5, there exists the previously mentioned ICD, now in its 10th revision (ICD–10) with the 11th revision due in 2017. The American Psychological Associa- tion (2009) offers a comparison of the DSM and ICD. ICD is a prod- uct of the WHO and was the culmination of an international effort from its inception. In contrast, DSM–III was initially characterized by minimal international participation and was notably different from its then-companion ICD–8. However, these different coding systems have become more similar with subsequent iterations and increasing collabo- ration between the two organizations.
Although it has been suggested that the DSM will eventually be unjustifiable to maintain as a separate diagnostic system from ICD, it is also suggested that DSM will continue to be useful because of its inclu- sion of details of mental health disorders that will never be incorporated in the ICD (American Psychological Association, 2009). The most recent edition of the DSM attempts to maintain its utility in a health care system that uses ICD codes for billing and reimbursement purposes. Accord- ing to the DSM–5’s website (American Psychiatric Association, 2014b), DSM–5 provides a dual code system, including ICD–9 and ICD–10 codes with DSM–5 diagnoses, in an effort to provide sufficient information needed to assign ICD–10 diagnoses to patients. It is also noteworthy that ICD and DSM are intended for different audiences, with ICD focus- ing on maximizing clinical utility for nonspecialist medical providers (Stein, Lund, & Nesse, 2013). Thus, both systems will likely maintain some utility in their respective professional groups. Psychologists are considered to be included in this nonspecialist medical providers group and therefore are required to use ICD codes under the Affordable Care Act for insurance reimbursement purposes.
In addition to DSM and ICD, the National Institute of Mental Health (NIMH) developed the Research Domain Criteria (RDoC) system in an attempt to find the basic, universal components of disordered thought and behavior and bolster research connecting clinical symptoms with underlying neurobiological mechanisms (Doherty & Owen, 2014; Stein et al., 2013). The RDoC system conceptualizes mental disorders as dis- orders of neurocircuitry with a biopsychosocial influence. It is hoped that the RDoC system will stimulate research that can help bridge the gap in our understanding between what we observe in the clinic and the biological and physiological substrates from which these symptoms emerge (Stein et al., 2013). At present, NIMH is encouraging RDoC research to remain independent of ICD and DSM work to minimize restrictions in research direction (Doherty & Owen, 2014).
Stein et al. (2013) pointed out that all three of these classification systems have their benefits and drawbacks and that a true understand-
Co py
ri gh
t Am
er ic
an P sy
ch ol og ic al A ss oc ia ti on . No t fo r fu
rt he
r di
st ri
bu ti
on .
79Psychopathology and Use of the Diagnostic and Statistical Manual
ing of mental health concerns, an understanding that considers the contexts of global and public mental health, heterogeneous presenta- tions, and multicausality, will require an understanding of all three of these systems. They posited that for one to gain a better understanding of psychopathology and its treatment, one must analyze the complex, multilevel mechanisms of mental disorders emphasized by all of these classification systems.
Neurodevelopmental Disorders
The group of conditions with an onset during childhood is qualified as neurodevelopmental disorders. This qualification is primarily due to the nature of the disorders’ manifestations early in development and may include developmental deficits involving personal, social, academic, and occupational functioning. Within this group, the range of develop- mental deficits can vary from global impairments in social skills or intel- lectual functioning to very specific limitations in learning or control of executive functioning. Included within this category are disorders char- acterized by deficits in intellectual, communication, relational, motor, and learning abilities.
For example, Intellectual Disability is one disorder within this group that is characterized by generalized deficits in mental abilities, includ- ing reasoning, problem solving, planning, abstract thinking, judgment, academic learning, and experiential learning. The resulting impairment in adaptive functioning of this disorder limits the individual in attain- ing standards of personal independence and social responsibility in one or more areas of daily living (e.g., communication, social, academic, occupational functioning).
Another disorder in this group, Global Developmental Delay, which can result in similar impairments, is diagnosed when expected develop- mental milestones are not met in several areas of functioning. This diag- nosis is often appropriate for individuals who are unable to undergo standardized assessments of functioning, including young children who are not old enough for such tests. Although intellectual disability occurs in all races and cultures, it is important to consider the individual’s cultural, ethnic, and linguistic background when assessing for such a disability.
Disorders defined by communication difficulties also fall under the umbrella of neurodevelopmental disorders due to onset early in life and possible lifelong functional impairments. These include language dis- order (deficits in the development and use of language), speech-sound disorder (deficits in the development and use of speech), and social
Co py
ri gh
t Am
er ic
an P sy
ch ol og ic al A ss oc ia ti on . No t fo r fu
rt he
r di
st ri
bu ti
on .
80 C h e r r y e t a l .
(pragmatic) communication disorder (deficits in the development and use of social communication). Childhood-Onset Fluency Disorder is also clustered with these communication disorders and is characterized by disturbances in the motor production and normal fluency of speech.
Persistent deficits in social communication and interaction across multiple settings characterize autistic spectrum disorder. These deficits can include problems in social reciprocity, nonverbal communication, and skills in developing and maintaining relationships. In addition to these deficits in social communication, restricted, repetitive patterns of behavior, interests, or activities are required to meet criteria for this disorder. It is important to consider cultural differences in norms for social interactions, nonverbal communication, and relationships. How- ever, individuals with autism spectrum disorder are diagnosed due to being markedly impaired against the norms of their individual culture. Various specifiers are used to individualize and clearly communicate individuals with this disorder.
Another neurodevelopmental disorder, Attention-Deficit/Hyper- activity Disorder (ADHD), is characterized by impairments in attention, disorganization, hyperactivity–impulsivity, or a combination of these. Examples of problems in inattention and disorganization include diffi- culty staying on task, losing things, and seeming not to listen, whereas examples of hyperactivity–impulsivity include being overly active, fidget- ing, difficulty staying seated, interrupting others, and difficulty waiting turns. It is also expected that these symptoms are to be present at levels excessive of age and developmental level. This disorder, although typi- cally first appearing in childhood, can persist into adulthood with result- ing impairments in social, academic, and occupational functioning.
Neurodevelopmental disorders involving deficits in motor abili- ties include developmental coordination disorder, which is defined by deficits in acquiring and executing coordinated motor skills. Individuals with this disorder demonstrate clumsiness and slowness or inaccuracy of motor skills, which result in interference in activities of daily living. Individuals with repetitive, purposeless, and seemingly driven motor behaviors that result in impairment in functioning are diagnosed with Stereotypic Movement Disorder. Examples of such behavior include body rocking, hand flapping, head banging, and self-biting. In con- trast, individuals with motor or vocal tics (sudden, rapid, recurrent, nonrhythmic, stereotyped motor movements or vocalizations) are diagnosed within tic disorder diagnoses. Tourette disorder is diagnosed when both motor and vocal tics are present for at least a year. Persistent Motor or Vocal Tic Disorder is given when only motor tics or vocal tics are present. Race, ethnicity, and culture may affect how tic disorders are perceived and managed by a family and community, which can then influence patterns of help seeking or acceptance of treatment choices.
Co py
ri gh
t Am
er ic
an P sy
ch ol og ic al A ss oc ia ti on . No t fo r fu
rt he
r di
st ri
bu ti
on .
81Psychopathology and Use of the Diagnostic and Statistical Manual
Finally, among the neurodevelopmental disorders that entail defi- cits in learning abilities is Specific Learning Disability. This diagnosis is given when an individual experiences deficits in the ability to perceive or process information efficiently and accurately in a specific area. As a result, the individual’s performance in the affected academic area is below average for age, level of education, or what is expected given the individual’s intellectual abilities. This diagnosis typically manifests early in the years of formal schooling and continues to cause impair- ment in learning skills in reading, writing, or math (or a combination of these) throughout schooling. Assessment for specific learning dis- abilities should take into account the linguistic and cultural context of the individual in addition to the individual’s educational and learning history in the original culture and language.
Schizophrenia Spectrum and Other Psychotic Disorders
Key features of diagnoses within the schizophrenia spectrum include positive symptoms (delusions, hallucinations, disorganized thinking, grossly disorganized or abnormal motor behavior) and negative symp- toms. The positive symptoms of schizophrenia are referred to as positive because their presentation is an excess in or distortion of the individu- al’s normal functioning; negative symptoms refer to a decrease in or loss of normal functions. Positive symptoms of schizophrenia are characterized by disturbances in thinking, perceptions of reality, and disorganized or abnormal behaviors. Delusions are defined as fixed beliefs that are both false and unresponsive to change despite evidence against these thoughts. Common content themes of delusions include persecutory, referential (i.e., thinking certain environmental cues, such as a song or a passage from a book, are directed at the individual), grandiose, erotomanic, nihilistic, and somatic delusions. Hallucinations are per- ceived experiences that occur with the absence of an external stimulus. These experiences are vivid, clear, and lack voluntary control. However, within some cultural contexts, hallucinations may be seen as a normal part of a religious experience. The presence of disorganized thinking is most commonly assumed from the individual’s speech as evidenced by switching topics rapidly (derailment or loose associations), responding in a tangential manner, or so disorganized that the person can hardly be comprehended (e.g., word salad). Grossly disorganized or abnor- mal behavior can include catatonia (i.e., unresponsiveness or stupor) and can be manifest in a variety of ways and intensities. Finally, nega- tive symptoms within the schizophrenia spectrum are characterized by
Co py
ri gh
t Am
er ic
an P sy
ch ol og ic al A ss oc ia ti on . No t fo r fu
rt he
r di
st ri
bu ti
on .
82 C h e r r y e t a l .
mental abilities that the patient has lost or abilities that the patient can no longer perform. Negative symptoms include diminished emotional expression, including flattened affect, lack of eye contact, and intonation in speech or nonverbal actions that give emphasis to speech; avolition, which is a decrease in motivation to complete self-initiated purposeful activities; alogia, which is a diminished speech output; anhedonia, or decreased ability to perceive pleasure from positive stimuli; and asocial- ity with a lack of interest in social interactions.
Delusional Disorder and Catatonia are two conditions defined by abnormalities limited to one domain of psychosis (e.g., delusions and grossly disorganized or abnormal behavior). Brief Psychotic Disorder, Schizophreniform Disorder, and Schizophrenia are primarily differen- tiated by duration in the abnormalities. Brief Psychotic Disorder has a duration of more than 1 day but remits by 1 month; Schizophreniform Disorder has a duration of less than 6 months; and schizophrenia lasts for at least 6 months, and generally much longer, with at least 1 month of having active symptoms.
Mood-Related Disorders
In regard to the following two sections of the DSM–5, Bipolar and Related Disorders and Depressive Disorders, it is imperative to under- stand the criteria required for meeting Manic, Hypomanic, and Major Depressive Episodes.
A manic episode is characterized by a distinct period of abnormally and persistently elevated, overly expansive mood, as well as abnor- mally persistent and increased goal-directed activity or energy with a duration of 1 week or longer. Three or more of the following symptoms must also be present: inflated self-esteem or grandiosity, decreased need for sleep, more talkative or pressured speech, racing thoughts, distracti- bility, psychomotor agitation, and high-risk behaviors. A Manic episode causes significant impairment in social or occupational functioning and often requires hospitalization.
A Hypomanic Episode differs from a manic episode in duration and severity. A Hypomanic Episode must last for at least 4 consecutive days and does not cause marked impairment in social or occupational func- tioning sufficient to require hospitalization.
A Major Depressive Episode has a minimum duration of 2 weeks and includes five or more of the following symptoms: depressed mood, marked or diminished interests or pleasure in activities, appetite distur- bance, sleep disturbance, fatigue or loss of energy, diminished ability to think or concentrate, and recurrent thoughts of death or suicide. These
Co py
ri gh
t Am
er ic
an P sy
ch ol og ic al A ss oc ia ti on . No t fo r fu
rt he
r di
st ri
bu ti
on .
83Psychopathology and Use of the Diagnostic and Statistical Manual
symptoms also must be severe enough to cause significant impairment in social and occupational functioning.
Bipolar and Related Disorders
To meet criteria for Bipolar I disorder, full criteria for at least one manic episode must be met. Although it is not necessary to meet criteria for a major depressive episode for a diagnosis of Bipolar I disorder, most individuals with this disorder experience major depressive episodes. In contrast, the diagnosis of Bipolar II disorder requires the experience of at least one episode of hypomania and at least one episode of major depression during the person’s lifetime. Because of their significant mood instability, individuals with this disorder often experience signifi- cant impairment in academic, work, and social functioning. For adults experiencing at least 2 years’ duration of hypomanic and depressive symptoms (1 full year for children) without meeting full criteria for a mania, hypomania, or major depressive episode, a diagnosis of cyclo- thymic disorder can be given.
Depressive Disorders
The presence of sad, empty, or irritable mood is the common feature of the depressive disorders, which differ in terms of their duration, timing, and presumed etiology. The mood disturbance component of depres- sive disorders is accompanied by somatic and cognitive changes that significantly interfere with tasks of daily functioning. Major depressive disorder is diagnosed with change in affect, cognition, and neurovegeta- tive functions occurring during a discrete episode of 2 weeks or longer. Dysthymia, in contrast, is an appropriate diagnosis for a more chronic and persistent form of depressive disorder that has mood disturbance with a duration of at least 2 years in adults and 1 year for children.
Although Bereavement is not included in the Depressive Disorders Category, it is often necessary to distinguish it from Major Depressive Disorder. It is helpful to remember that with bereavement, the pre- dominant feelings are of loss and emptiness, whereas in Major Depres- sive Disorder, depressed mood and inability to anticipate happiness or pleasure are predominant. In addition, grief is often experienced in waves, whereas depression is more likely persistent and not tied to any specific thoughts or reminders.
Co py
ri gh
t Am
er ic
an P sy
ch ol og ic al A ss oc ia ti on . No t fo r fu
rt he
r di
st ri
bu ti
on .
84 C h e r r y e t a l .
Within the depressive disorders category, two new diagnoses were added to the DSM–5. One is the Disruptive Mood Dysregulation Dis- order which is characterized by severe and recurrent temper outbursts as well as chronic and severe irritability. The recurrent temper tantrums must be inconsistent with the developmental level of the individual and have a frequency of three or more times per week. The other, Pre- menstrual Dysphoric Disorder, is characterized by mood disturbance present in the week before menses that weaken or diminish the week after menses.
Anxiety Disorders
This group of disorders is characterized by excessive fear, anxiety, and related behavioral problems. The anxious person has an emotional response to a real or perceived threat, either present or expected to occur. Many of these disorders can overlap; however, they also can dif- fer in the objects or situations that elicit fear, anxiety, avoidance behav- ior, and associated cognitions. Anxiety disorders are different from developmentally normative fears in that they are excessive or persist beyond what is deemed appropriate and cause significant distress or impairment in social, academic, occupational, or other functioning. The patient may not recognize that the fear is disproportional to the stressor, so it may be up to the clinician to decide if the patient’s fear is excessive given the patient’s thoughts, behaviors, and cultural context.
A few disorders previously categorized under disorders of infancy and childhood have been moved to the anxiety disorders classification because it has been recognized that these disorders can occur across the life span. For example, separation anxiety disorder includes excessive fear related to separation from home or major attachment figures. The patient may fear that his or her attachment figure will be harmed or lost or that some event will occur with the patient (e.g., getting lost or kidnapped) that will prevent contact with the attachment figure. Actual or anticipated separation from the attachment figure may also lead to somatic complaints, including headaches, stomachaches, and other physi- cal symptoms. Separation anxiety disorder is the most prevalent anxiety disorder in children under 12 years of age, with prevalence decreasing with age. The onset of the disorder can occur in adulthood as long as the fear is not transient.
Selective mutism is characterized by consistent failure to speak in social situations during which one is expected to speak. The patient is able to speak in other situations (i.e., the disturbance is not the result of a communication disorder) and has sufficient knowledge of and com-
Co py
ri gh
t Am
er ic
an P sy
ch ol og ic al A ss oc ia ti on . No t fo r fu
rt he
r di
st ri
bu ti
on .
85Psychopathology and Use of the Diagnostic and Statistical Manual
fort with the required spoken language. Selective mutism is often asso- ciated with social anxiety disorder or other anxiety disorders.
Specific phobia consists of fear or anxiety related to or avoidance of certain objects or situations. In children, this fear may manifest itself as crying, tantrums, freezing, or clinging behaviors. The phobic stimulus must consistently produce fear, anxiety, or avoidance; be persistent (i.e., occur for at least 6 months); and cause significant distress or impairment. Possible phobic situations and objects vary and can include animals; the natural environment (e.g., storms, heights, water); blood, injection, and injury (e.g., needles, medical procedures); situational contexts (e.g., planes, elevators, enclosed spaces); and other stimuli (e.g., loud noises, costumes, choking or vomiting). Many patients have multiple phobias.
Individuals with social anxiety disorder exhibit fear or anxiety in one or more social situations varying from daily activities (e.g., con- versing, meeting new people, eating or drinking in public) to particular events (e.g., giving a speech). In children, this fear must interfere with interactions with peer as well as with adults. The fear relates to the patient’s thinking she or he will behave in a way that others will eval- uate negatively, leading to humiliation, embarrassment, or rejection. Because of this fear, patients may avoid situations or endure them with intense discomfort. People from Asian cultures (e.g., Japan, Korea) may develop a fear that they will make other people feel uncomfortable rather than fear of personal discomfort.
Panic Disorder consists of recurrent, unexpected panic attacks followed by either fear of additional attacks or significant behavioral change related to attacks. A panic attack is an abrupt surge of fear or discomfort that peaks in minutes. These attacks can follow calm or anx- ious emotional states and can include increased heart rate, palpitations, sweating, shaking, difficulty breathing, chest pain, abdominal upset, dizziness, numbness or tingling, derealization, depersonalization, and fear of losing control or dying. Patients can interpret these symptoms as significant health concerns, leading to unnecessary hospitalizations, emergency room visits, absences from work or school, and, ultimately, unemployment or attrition. Panic attacks can be added as a specifier to any DSM–5 disorder. Rates of panic disorder are significantly higher in American Indian populations, followed by non-Latino whites. Females are twice as likely to be affected.
Agoraphobia includes excessive fear or anxiety about situations in which the individual perceives it may be difficult to escape or get help should paniclike or other incapacitating or embarrassing symp- toms arise. This fear leads to avoidance of such situations (e.g., public transportation, open or enclosed spaces, crowds, other places outside of the home). At its most extreme, agoraphobia may render people com- pletely homebound and dependent on others.
Co py
ri gh
t Am
er ic
an P sy
ch ol og ic al A ss oc ia ti on . No t fo r fu
rt he
r di
st ri
bu ti
on .
86 C h e r r y e t a l .
When individuals experience excessive, difficult-to-control anxiety and worry about multiple events or activities, they may meet diagnostic criteria for generalized anxiety disorder. The subject of worry can vary (e.g., work-related responsibilities, health, finances, family members, school). Affected individuals may experience restlessness, fatigue, dif- ficulty concentrating, irritability, muscle tension, or sleep difficulties. People with generalized anxiety may also display headaches, muscle soreness, sweating, nausea, and diarrhea. Culturally, generalized anxi- ety disorder tends to occur more in individuals of European descent and individuals from developed countries.
Obsessive–Compulsive and Related Disorders
This group of diagnoses is characterized by obsessions (i.e., recur- rent and persistent thoughts, urges, or images that are intrusive and unwanted) and compulsions (e.g., repetitive behaviors or mental acts that the individual feels driven to perform). Obsessive–Compulsive Disorder (OCD) is characterized by the presence of both obsessions and compulsions, which are time-consuming and/or cause distress or impairment in social, occupational, or other types of functioning. OCD occurs worldwide; however, cultural context may shape the content of the obsessions and compulsions. Other presentations of OCD are char- acterized by either cognitive factors or recurrent body-focused repeti- tive behaviors. Of those characterized by cognitive symptoms, Body Dysmorphic Disorder includes perceived defects or flaws in physical appearance, whereas Hoarding Disorder includes the perceived need to save possessions. Trichotillomania (hair pulling) and excoriation (skin picking) are characterized by recurrent, body-focused behaviors.
Trauma- and Stressor-Related Disorders
This category of disorders includes those in which exposure to a trau- matic or stressful event is part of the diagnostic criteria. The five primary disorders in this category represent a broad range of symptoms and are reflective of the variable psychological distress response individuals can experience following exposure to a traumatic or stressful event. These symptoms include anxiety- or fear-based symptoms, anhedonic and
Co py
ri gh
t Am
er ic
an P sy
ch ol og ic al A ss oc ia ti on . No t fo r fu
rt he
r di
st ri
bu ti
on .
87Psychopathology and Use of the Diagnostic and Statistical Manual
dysphoric symptoms, externalizing angry and aggressive symptoms, and dissociative symptoms. Reactive Attachment Disorder and Disinhibited Social Engagement Disorder require social neglect or the absence of adequate caregiving during childhood as a diagnostic requirement. Although these two disorders share a common etiology, the expression of symptoms is quite different and distinct, with attachment disorder characterized by internalizing symptoms such as depressive symptoms and withdrawn behavior and disinhibited social engagement disorder characterized by disinhibition and externalizing behavior.
Specifically, Reactive Attachment Disorder occurs in infancy or early childhood and is characterized by an absent or grossly under- developed attachment between the child and caregiving adults. When distressed, these children make no significant attempts to obtain com- fort or support from caregivers and do not respond to comforting efforts of caregivers. Because of their compromised emotion regulation capacity, these children will display unexplained episodes of negative emotions of fear, sadness, or irritability.
Disinhibited Social Engagement Disorder is characterized by a pat- tern of behavior that involves culturally inappropriate, overly familiar behavior with relative strangers, such as approaching and interacting with unfamiliar adults or willingness to go off with an unfamiliar adult. This disorder may co-occur with developmental delays, especially cog- nitive and language delays, and other signs of severe neglect, such as malnutrition.
Posttraumatic stress disorder (PTSD) is characterized by exposure to actual or threatened death, serious injury, or sexual violence and the presence of the following: intense and intrusive memories of the trau- matic event; persistent avoidance of stimuli associated with the traumatic event; negative alterations in cognitions and mood associated with the traumatic event; and increased arousal and reactivity associated with the traumatic event. The duration of these symptoms is more than 1 month and results in clinically significant distress or impairment in social, occupational, or other important areas of functioning. There is an increased suicide risk for individuals who have experienced trau- matic events such as childhood abuse. Also, PTSD is associated with suicidal ideation and suicide attempts.
The diagnostic features of Acute Stress Disorder are similar to those of PTSD, but the duration of symptoms is 3 days to 1 month after expo- sure to one or more traumatic events. It is estimated that half of indi- viduals who develop PTSD initially experienced an acute stress disorder.
Adjustment Disorders are characterized by emotional or behavioral symptoms in response to an identifiable stressor(s) occurring within 3 months of the onset of the stressor(s). Symptoms result in marked distress beyond what is expected and cause impairment in social, occu- pational, or other important areas of functioning.
Co py
ri gh
t Am
er ic
an P sy
ch ol og ic al A ss oc ia ti on . No t fo r fu
rt he
r di
st ri
bu ti
on .
88 C h e r r y e t a l .
Dissociative Disorders
Dissociative disorders include disruptive symptoms related to one’s con- sciousness, memory, identity, emotion, perception, body representation, motor control, and behavior. These symptoms may be experienced as losses of continuity in subjective experience, such as a loss of identity, depersonalization (i.e., subjective experience of detachment or observ- ing one’s own speech and actions; an “out of body experience”), and derealization. They can also occur as an inability to access informa- tion, such as amnesia. Dissociative disorders often occur after a trauma. Before diagnosing these disorders, it is important that the clinician deter- mine whether symptoms occur as part of culturally acceptable practices (e.g., religious experience, childhood pretend play) or due to substance use or a co-occurring medical condition (e.g., complex partial seizures).
Dissociative Identity Disorder includes a disruption of identity in which an individual has at least two distinct personality states. This disruption can affect a person’s sense of self, sense of agency or control, affect, behavior, consciousness, memory, perception, cognition, and sensorimotor functioning. In children, it is important to ensure that symptoms are not better accounted for by fantasy play. People with dis- sociative identity disorder may also experience dissociative fugues in which they “come to” in a location without knowing how they arrived there. Symptoms can be influenced by cultural factors and may present as unexplained neurological symptoms or perceived demonic or spiritual possession.
Dissociative Amnesia is characterized by forgetting of important personal information, usually related to traumatic or stressful events. These symptoms are more severe than ordinary forgetfulness and can relate to isolated incidents or generalize to one’s entire identity or life history. Dissociative amnesia can also occur with fugue. Onset for gen- eralized amnesia is usually sudden, but it may be more difficult to assess for selective amnesias because the patient does not realize or report forgotten events. Dissociated memories may be regained with time and removal from the traumatic situation. However, recovered memories may lead to further distress, suicidality, or posttraumatic symptoms.
Depersonalization includes the experience of unreality, detach- ment, or outwardly observing one’s own thoughts, feelings, sensations, body, or actions (e.g., “out-of-body experience”). Derealization relates to the experience of unreality or detachment from one’s surroundings (e.g., individuals or objects appear distorted). In depersonalization- derealization disorder, the affected individual may experience either or both of these symptoms. During these dissociative experiences, the individual can still differentiate between perception and reality but may
Co py
ri gh
t Am
er ic
an P sy
ch ol og ic al A ss oc ia ti on . No t fo r fu
rt he
r di
st ri
bu ti
on .
89Psychopathology and Use of the Diagnostic and Statistical Manual
feel “in a fog” or emotionally numb. Although approximately half of adults have experienced transient depersonalization or derealization symptoms, relatively few meet full criteria for this disorder.
Somatic Symptoms and Related Disorders
This grouping of disorders reflects another new category in DSM–V, with all disorders sharing a common feature: the prominence of somatic symptoms associated with significant distress and impairment. Individuals with these disorders may or may not have an actual medi- cal diagnosis and are typically encountered in primary care and other medical settings.
Somatic Symptom Disorder is characterized by one or more somatic complaints that are distressing and result in significant disruption to daily life. Additionally, individuals must display abnormal thoughts, feelings, and behaviors in response to these symptoms, such as dispro- portionate and persistent thoughts about the seriousness of their symp- toms, persistently high level of anxiety about their health or symptoms, or engage in excessive time and energy devoted to their symptoms or health concerns. In individuals with this disorder, it is less about the specific symptoms and more about how the individual presents and interprets his or her symptoms.
Another newly described disorder, Illness Anxiety Disorder, has preoccupation with having or acquiring a serious illness for at least 6 months as a central feature. Individuals with this disorder also have a high level of anxiety about health and either perform excessive health- related behaviors or display maladaptive avoidance.
Conversion Disorder (Functional Neurological Symptom Disorder) includes one or more symptoms of altered voluntary motor or sensory functioning for which there is an inconsistency between the symptom(s) and recognized neurological or medical conditions. In individuals with a disorder of Psychological Factors Affecting Other Medical Conditions, there is the presence of one or more psychological or behavioral factors (e.g., symptoms of depression or anxiety, stressful life events, coping styles) that adversely affect a medical condition by increasing the risk for suffering, death, or disability.
Factitious Disorder is characterized by the falsification of symptoms (medical or psychological) in oneself or others. Additionally, the individ- ual may do this in the absence of obvious external rewards but seeks to appear more ill or impaired, which can lead to excessive clinical interven- tion and attention.
Co py
ri gh
t Am
er ic
an P sy
ch ol og ic al A ss oc ia ti on . No t fo r fu
rt he
r di
st ri
bu ti
on .
90 C h e r r y e t a l .
Feeding and Eating Disorders
This category includes six disorders in which disturbance of eating or eating-related behavior has an impact on consumption or absorption of food and there is significant impairment in psychosocial function- ing or physical health. All but one disorder (Pica) in this category have diagnostic criteria that are mutually exclusive, so individuals can receive only one diagnosis during a single episode. Pica can be diagnosed simul- taneously with any of the other feeding or eating disorders. This disorder is characterized by eating of nonnutritive, nonfood substances, which is developmentally inappropriate and not part of a culturally supported behavior. In contrast, Rumination Disorder involves the repeated regur- gitation of food over a period of 1 month, which is not due to a medi- cal condition. Individuals meeting criteria for Avoidant/Restrictive Food Intake Disorder avoid or restrict food intake, which results in failure to meet nutritional requirements. Anorexia Nervosa is characterized by the following three primary features: persistent food restriction, which leads to significantly low body weight; an intense fear of gaining weight or becoming fat, despite being at a significantly low weight; and disturbed perception of the individual’s body weight or shape. An individual with Bulimia Nervosa engages in recurrent binge eating and inappropriate compensatory behaviors (self-induced vomiting; misuse of laxatives, diuretics, or other medications; fasting; or excessive exercise) to prevent weight gain. Last, Binge-Eating Disorder is characterized by recurrent episodes of binge eating that occur at least once a week for 3 months, and distress over the binge-eating episodes. The individual engaging in excessive food intake must experience a lack of control over the eating for the episode to be considered binge eating. Individuals with binge- eating disorder do not engage in inappropriate compensatory behaviors as in bulimia nervosa.
Elimination Disorders
Elimination disorders involve elimination of urine (enuresis) or feces (encopresis) into inappropriate places (e.g., in one’s clothing, in bed, on the floor). These behaviors can occur during the day, night, or both and are considered inappropriate according to developmental age (defined as 5 years for enuresis and 4 years for encopresis). Inappropriate void- ing of urine or passage of feces can be either voluntary or involuntary. Enuresis and encopresis typically occur separately but can co-occur. To meet diagnostic criteria, duration of soiling for both enuresis and
Co py
ri gh
t Am
er ic
an P sy
ch ol og ic al A ss oc ia ti on . No t fo r fu
rt he
r di
st ri
bu ti
on .
91Psychopathology and Use of the Diagnostic and Statistical Manual
encopresis must be 3 months, although required frequency differs (at least twice weekly for enuresis and once monthly for encopresis). Specifiers for encopresis include with or without constipation and over- flow incontinence. Elimination disorders have two courses: the primary type describes individuals who have never achieved urinary or fecal continence, and the secondary type describes those who develop symp- toms after establishing continence.
Sleep–Wake Disorders
This collection of disorders involves sleep–wake complaints related to the quality, quantity, and timing of sleep. As a result of insufficient sleep, individuals with a sleep disorder may have functional difficul- ties or distress during the day (e.g., fatigue, daytime sleepiness). Sleep difficulties may present with comorbid depression, anxiety, and cogni- tive deficits (e.g., difficulties concentrating, attending, remembering) and may increase the risk of a patient developing other mental health concerns. Furthermore, sleep difficulties may be a clinical feature of additional mental health problems (e.g., major depression).
The broad category of sleep–wake disorders include insomnia, hyper- somnolence disorder, and narcolepsy. Insomnia is characterized by dif- ficulties initiating or maintaining sleep. Children with insomnia may be able to initiate or return to sleep only with caregiver assistance. The disturbance must occur at least 3 nights per week, persist for at least 3 months, and occur despite adequate opportunity to sleep. Insomnia is the most common sleep disorder, with approximately a third of adults reporting symptoms.
Hypersomnolence disorder consists of excessive sleepiness and dif- ficulty staying awake during the day despite at least 7 hours of sleep at night. Like insomnia, symptoms must occur at least 3 times per week for at least 3 months before diagnosing.
A similar disorder, narcolepsy consists of recurring periods of irrepressible sleep multiple times per day. Diagnosis requires at least one of the following: cataplexy (brief episodes of sudden loss in muscle tone or spontaneous grimaces, jaw opening, or tongue thrusting behaviors), documented hypocretin deficiency, or nocturnal sleep polysomnogra- phy documenting rapid-onset REM sleep or mean sleep latency less than or equal to 8 minutes and at least two sleep-onset REM periods. Indi- viduals with narcolepsy may display automatic behaviors (“auto pilot”), vivid hypnagogic hallucinations, sleep paralysis, nocturnal eating, or nightmares. Individuals with true narcolepsy, as opposed to conversion disorder, will not have reflexes during cataplexy.
Co py
ri gh
t Am
er ic
an P sy
ch ol og ic al A ss oc ia ti on . No t fo r fu
rt he
r di
st ri
bu ti
on .
92 C h e r r y e t a l .
The second category of sleep disorders, Breathing-Related Sleep Dis- orders, includes obstructive sleep apnea hypopnea, central sleep apnea, and sleep-related hypoventilation. The most common breathing-related sleep disorder, obstructive sleep apnea hypopnea, consists of multiple episodes of upper airway obstruction during sleep (with apnea being total blockage of airflow and hypopnea being partial reduction in air- flow) as documented by polysomnography. Furthermore, these patients exhibit daytime sleepiness, nighttime snoring or gasping, fatigue, or unrestorative sleep despite sufficient opportunity. Central sleep apnea disorders are characterized by periodic breathing, that is, hyperventila- tion alternating with hypoventilation, or variations in respiratory effort without evidence of obstruction. This form of apnea may co-occur with obstructive sleep apnea hypopnea syndrome, a condition known as complex sleep apnea. Although they can also be asymptomatic, indi- viduals with central sleep apnea may present with sleepiness, insom- nia, and frequent awakenings due to shortness of breath. Sleep-related hypoventilation can be observed during polysomnography as episodes of decreased respiration leading to increased CO2 levels or decreases in hemoglobin oxygen saturation. These conditions may also be associated with daytime sleepiness, nighttime awakenings, morning headaches, and insomnia. They may also co-occur with obstructive sleep apnea hypopnea or central sleep apnea.
Circadian Rhythm Sleep-Wake Disorders relate to persistent or recurrent sleep disruption due to an altered circadian system or a mis- match between the patient’s circadian rhythm and the sleep–wake schedule demanded by the patient’s environment. There are six sub- types of circadian rhythm sleep–wake disorders: delayed sleep phase type (onset and awakening too late), advanced sleep phase type (onset and awakening too early), irregular sleep–wake type, non–24-hour sleep–wake type (consistent daily drift, usually later and later), shift work type, and unspecified type. This group of disorders is often diag- nosed with the assistance of a detailed sleep diary or actigraphy, which is the objective measuring of gross motor activity during sleep. These sleep disturbances cause excessive sleepiness and/or insomnia. In delayed and advanced sleep phase types, the individual would have normal sleep quality and duration if allowed to set his or her own sleep sched- ule independent of social, occupational, or environmental constraints. However, these two types go beyond normative “early birds” and “night owls,” and sleep phase is generally shifted 2 to 4 hours earlier or later than desired or deemed conventional.
The group of disorders describing the abnormal behavioral, experi- ential, or physiological events related to sleep are known as Parasom- nias. Sleepwalking and sleep terrors are manifestations of incomplete awakening from sleep. These are typically brief (i.e., 1–10 minutes, but can be longer) phenomena that usually occur during the first third of
Co py
ri gh
t Am
er ic
an P sy
ch ol og ic al A ss oc ia ti on . No t fo r fu
rt he
r di
st ri
bu ti
on .
93Psychopathology and Use of the Diagnostic and Statistical Manual
one’s sleep cycle during slow-wave, deep sleep. It is extremely difficult to awaken someone during episodes of sleepwalking or sleep terrors. Following sleepwalking or terror events, individuals will typically not recall the event or any dreams associated with the event. Subtypes of sleepwalking behavior include sleep-related eating behavior and sleep- related sexual behavior.
Unlike sleep terrors, the dreams of nightmare disorder are well remembered and upsetting, usually involving themes of threats to sur- vival, security, or physical integrity. These dreams typically occur during the second half of sleep (i.e., REM sleep), and the affected individual usually becomes quickly oriented and alert upon awakening.
REM sleep behavior disorder includes “dream-enacting behaviors” (e.g., vocalization and/or complex motor behaviors) occurring during REM sleep, typically 90 minutes after sleep onset and more frequently during the later portions of sleep. Behaviors related to this disorder can be disruptive and alarming and can include running, punching, and screaming, for example. REM sleep behavior disorder can be associated with an underlying neurodegenerative disorder (e.g., Parkinsonism) and tends to occur in men aged 50 years or older.
Restless legs syndrome is a sensorimotor, neurological sleep dis- order that involves an urge to move legs or arms to relieve uncomfort- able tingling, burning, or other sensations. This urge worsens during inactivity and at night. This disorder disrupts sleep by delaying onset or causing nighttime awakenings. This can negatively affect mood and energy and can lead to depressive, generalized anxiety, panic, and post- traumatic stress disorders. During a sleep study, individuals with restless legs syndrome likely exhibit periodic leg movements during sleep and wakefulness.
Sexual Dysfunctions
The rather diverse group of disorders classified within Sexual Dysfunctions all have one or two traits in common, and perhaps not much else, but they may coexist in the same patient. Their commonalities include an objec- tive realization of significant distress due to impairment in either sexual responsiveness or sexual pleasure that is not a result of a lack of adequate sexual stimulation and a period of 6 months or more of the associated symptoms. These disorders can be considered generalized, which means global, or unrelated to partner, situation, type of contact stimulation, or situational, in which they only happen under specific circumstances or with certain individuals. Disorders in this classification assume that the patient has adequate neurological and biological capacity and, with
Co py
ri gh
t Am
er ic
an P sy
ch ol og ic al A ss oc ia ti on . No t fo r fu
rt he
r di
st ri
bu ti
on .
94 C h e r r y e t a l .
the exception of one disorder, Substance/Medication-Induced Sexual Dysfunction, are assumed to be related to developmental or experien- tial barriers to response or pleasure. An additional designation, lifelong (implying since sexual maturity), differentiates these individuals from those who had a period of healthy sexual functioning before the onset of symptoms. Other significant factors that these disorders share include difficulties the current sexual partner may be facing; nonsexual inter- personal behavior in the relationship; comorbid psychiatric problems of the patient or vulnerability factors, which are subclinical but may affect functioning; cultural and religious issues; and any medical factors that may not have caused but may exacerbate the problem or make it more difficult to treat.
Some sexual dysfunctions are necessarily tied to sexual anatomy, making them specific to male and female patients. In the group of dis orders affecting males, Delayed Ejaculation is marked by a male’s distress in having significant unwanted delay in ejaculation most of the time, even when stimulated and experiencing pleasure. By con- trast, Premature Ejaculation is marked by distress at ejaculating within 1 minute of beginning vaginal intercourse. It does not account for time to ejaculation outside of vaginal intercourse because there are no clinical criteria established for this. Erectile Disorder is diagnosed in men who are having difficulty obtaining, maintaining, or keeping sufficiently rigid the penile erection during sexual activity in a majority of encounters that is not caused by medical problems. Male Hypoactive Sexual Desire Disorder is marked by a significant drop in or absence of interest in sexual activity and erotic thoughts and fantasies in the individual.
For females, a separate group of disorders with some significant similarities may be diagnosed. Female Orgasmic Disorder is character- ized by dysfunction in the experience of orgasm, either by decreased frequency or total absence, or significantly reduced intensity, which causes disruption of pleasure in most sexual activities. By contrast, Female Sexual Interest/Arousal Disorder, similar to Male Hypoactive Sexual Desire Disorder, describes elimination of or significant decrease in overall sexual function. Genito-Pelvic Pain/Penetration Disorder is a disorder in females characterized by a pattern of sensory pain before or during sexual activity.
Last, some issues may cause significant impairment or distress in either sex. A diagnosis of Substance/Medication-Induced Sexual Dysfunc- tion describes difficulties in either arousal or experience of pleasure that appear to be related to the use of certain substances, which may be ille- gal drugs or prescribed medications. Other Specified Sexual Dysfunc- tion describes conditions that cause significant distress and impairment of sexual function or experience but do not meet all necessary criteria for another sexual function disorder. Unspecified Sexual Dysfunction
Co py
ri gh
t Am
er ic
an P sy
ch ol og ic al A ss oc ia ti on . No t fo r fu
rt he
r di
st ri
bu ti
on .
95Psychopathology and Use of the Diagnostic and Statistical Manual
describes conditions that rise to the level of disorder related to sexual function or experience but for which the clinician chooses not to specify named symptoms or does not have enough information to be more specific.
Gender Dysphoria
Gender Dysphoria is marked by significant distress or functional impairment regarding the difference between an individual’s assigned (phenotypic/physical) gender and his or her expressed or desired gender. This distress must last at least 6 continuous months and must include a minimum of six related symptoms, including desiring, discussing, or manifesting physical, dress, and social and play attributes opposite to their assigned gender. The individual with this disorder can also mani- fest symptoms of dislike for her or his own sexual anatomy and desire for the anatomy and sex characteristics of the desired gender. The disorder has age designations (childhood, adolescence, and adulthood) based on the age at diagnosis, not the age at which the symptoms began, and can co-occur with biologically based disorders of sex devel- opment. If the criteria for this disorder are not fully met but several symptoms related to gender dysphoria cause significant distress or func- tional impairment, a diagnosis of Other Specified Gender Dysphoria or Unspecified Gender Dysphoria can be made.
Disruptive, Impulse Control, and Conduct Disorders
Broadly, these disorders involve problems in self-control of behavior and emotion that violate the rights of others or defy societal norms or author- ities. Individuals with oppositional defiant disorder exhibit a pattern of disruptive behavior related to angry/irritable mood, argumentative/ defiant behavior, or vindictiveness toward at least one nonsibling indi- vidual. These behaviors must be more severe than expected given one’s developmental level (i.e., occurring most days for children under age 5 and at least weekly for children 5 years and older). Oppositional defi- ant disorder may present with other disruptive behavior dis orders (e.g., ADHD) as well as depression, anxiety, substance abuse, and suicidality.
Intermittent explosive disorder includes physical or verbal (e.g., temper tantrums, arguing) and nondestructive aggressive outbursts.
Co py
ri gh
t Am
er ic
an P sy
ch ol og ic al A ss oc ia ti on . No t fo r fu
rt he
r di
st ri
bu ti
on .
96 C h e r r y e t a l .
These impulsive outbursts occur without warning and are grossly dis- proportionate to the provocative stressor(s). Furthermore, these behav- iors are anger-driven, impulsive, and not instrumental in nature. Left untreated, aggressive behavior associated with this disorder can lead to negative social consequences, employment issues, and legal concerns.
Conduct disorder is characterized by a pattern of behavior that vio- lates the rights of others or societal norms and can include aggression towards people or animals, destruction of property, deceitfulness or theft, or chronic violations of rules. Childhood onset (before age 10) of conduct disorder is likely to persist into adulthood; it typically occurs in males and includes physical aggression, peer relational problems, a history of oppositional behavior, and concurrent ADHD symptoms. In contrast, adolescent-onset (after age 10) conduct problems tend to occur equally in boys and girls, are less persistent, tend to be less aggres- sive in nature, and are less related to peer relationship problems. DSM–5 includes a conduct disorder specifier that allows the clinician to indicate limited prosocial emotions, including lack of guilt or empathy, apathy about performance, and shallow or superficial affect. Known as “callous and unemotional” traits in the research literature, this presentation tends to occur with childhood onset and more severe symptoms.
A pattern of purposeful and deliberate fire-setting behavior pre- ceded by tension or affective arousal characterizes pyromania. An indi- vidual with pyromania experiences pleasure or relief when setting fires or participating in the aftermath of a fire and may be apathetic of the consequences of his or her behavior. Pyromania does not include fire- setting behavior associated with anticipated monetary gain, expression of anger, sociopolitical ideology, or delusional or hallucinatory behav- ior. Similar to pyromania, kleptomania is characterized by a pattern of behavior (theft) that is preceded by tension and associated with plea- sure or relief during the act. In addition, items stolen are not needed for personal use or for monetary value, and the behavior is not an expression of anger or a result of delusional or hallucinatory behavior.
Substance-Related and Addictive Disorders
This category of disorders includes disorders associated with the use of 10 separate classes of drugs: alcohol, caffeine, cannabis, hallucinogens, inhalants, opioids, sedatives, stimulants, tobacco, and other substances. A feature of all substances taken in excess is that the substance use results in direct activation of the brain reward system. This system is involved in the reinforcement of behaviors and memory production. Because of
Co py
ri gh
t Am
er ic
an P sy
ch ol og ic al A ss oc ia ti on . No t fo r fu
rt he
r di
st ri
bu ti
on .
97Psychopathology and Use of the Diagnostic and Statistical Manual
the significant activation of the reward system by substances, normal activities or adaptive behaviors may be neglected, and substances are used to directly activate the reward system. For each of the 10 classes of drugs, an individual can be diagnosed with substance use disorder, sub- stance intoxication, or substance withdrawal. A substance use disorder is characterized by cognitive, behavioral, and physiological symptoms demonstrating that an individual continues to use the substance despite significant problems resulting from the substance use. An individual can be diagnosed with a substance use disorder for all of the substances listed earlier except caffeine. Although some individuals who consume caffeine have symptoms consistent with problematic use, like tolerance and withdrawal, current data are not available to determine the clini- cal significance of a caffeine use disorder or its prevalence. The primary feature for Substance Intoxication is the development of a reversible substance-specific syndrome due to recent ingestion of the substance. Tobacco is the only substance listed that does not apply to this category, because nicotine intoxication is rare. Substance Withdrawal is charac- terized by the development of a substance-specific problematic behav- ioral change, with physiological and cognitive symptoms, which is due to the cessation or reduction in heavy and prolonged substance use. Gambling Disorder is also included in this category of disorders due to the evidence that gambling behaviors activate reward systems similar to drugs of abuse. Individuals who meet criteria for this disorder engage in persistent and recurrent maladaptive gambling behavior that disrupts personal, family, or vocational pursuits.
Neurocognitive Disorders
Neurocognitive disorders share one feature that sets them apart. Each of the syndromes described involves disordered functioning for which the cause and type of current problems may be investigated and iden- tified medically. In fact, after the description of Delirium, which must have evidence of a direct relationship with causative factors such as substance ingestion or withdrawal, all other diagnoses in this category are made with designations of level of dysfunction (mild or major) and the suspected or known origin (e.g., Lewy bodies, which are irregularly shaped clumps of protein inside brain cells and other nerve cells that can cause functional change). What the diagnoses also share is acquired (separate from any developmental difficulties) functional and cogni- tive impairments, including problems of complex attention, executive function, learning and memory, language, perceptual–motor abilities, and social cognition. For each named disorder, a thorough history and
Co py
ri gh
t Am
er ic
an P sy
ch ol og ic al A ss oc ia ti on . No t fo r fu
rt he
r di
st ri
bu ti
on .
98 C h e r r y e t a l .
assessment is necessary to satisfy both the origin and the type and level of each functioning area, and there must be no better explanation for the symptoms related to physiological or mental disorders.
Delirium is identified and diagnosed on the basis of self-report or informant-report. The disorder entails significant problems with voli- tional attention, awareness (described as reduced orientation to the envi- ronment) and at least one other area of cognition. Patients may not remember details from earlier in the day, although they remember everything else (memory); they may not be able to “find” words easily when they are speaking (language production), or they have trouble walking without hitting objects or walls because of change in depth perception (visuospatial functioning). The symptoms appear in a rela- tively short period of time, fluctuate throughout the hours the patient is conscious, and show evidence of being caused by a diagnosable medical condition (known or unknown), a substance (drug or toxin ingestion or withdrawal), or multiple knowable causes. The designation of Neuro- cognitive Disorder Unspecified may only be used when the patient clearly meets all necessary criteria for a neurocognitive disorder but for which there is insufficient medical certainty of the cause or the clinician decides not to list it.
Major Neurocognitive Disorders (the clinician must identify the known cause or causes, or identify it as “unspecified”) are characterized by a major decline in cognitive function from a previously higher level in at least one cognitive functioning area as noticed by the individual or a reliable informant and documented by an acceptable level of assess- ment. In addition, the functioning difficulties must be known to cause impairment in ability to function independent of assistance; must not occur solely during a period of delirium; and cannot be explained by a different mental disorder known to cause cognitive impairment, such as schizophrenia. They typically demonstrate a quiet and sometimes unnoticeable onset with progression over time. By contrast, Mild Neuro- cognitive Disorder shows similar causal pathways and functional defi- cits but noticeably less disability of function. With this designation, the patient shows somewhat hampered cognitive function (e.g., attention, awareness, memory) and known functional impairment in behaviors of independence but can still function with some personal compensation strategies.
When possible, neurocognitive disorder must be given a classifica- tion related to the suspected cause. Known causes and specifiers for major and mild neurocognitive disorders such as Alzheimer’s disease, frontotemporal disorder (classified as the behavior and personality changes that accompany physical changes in brain tissue in the affected regions), Lewy bodies development, vascular changes (changes in cir- culation in the brain), traumatic brain injury, substance or medication,
Co py
ri gh
t Am
er ic
an P sy
ch ol og ic al A ss oc ia ti on . No t fo r fu
rt he
r di
st ri
bu ti
on .
99Psychopathology and Use of the Diagnostic and Statistical Manual
HIV infection, prion disease (damage to or infection in brain tissue by malformed proteins), Parkinson’s disease, or Huntington’s disease.
Personality Disorders
Personality Disorders comprise a group of diagnoses focusing on inter- personal and inwardly focused behaviors that are significantly differ- ent from social norms or expectations of others within the individual’s culture. Areas of disruption include the person’s thoughts and percep- tions, emotional behavior, relational behavior, and impulse control. The behaviors represented within these disorders can cause significant occupational, romantic, and other relational difficulties for the indi- vidual regardless of the individual’s perceived experience of difficul- ties or insight. The disordered behavior must be stable and pervasive; resistant to change; cannot be better explained as a result of a physio- logical cause, medical condition, or a different mental disorder; and must have some behavioral evidence from childhood or adolescence. These disorders, on the basis of research and areas of cognitive and relational disturbance, are grouped into clusters according to com- mon characteristics. Because the behaviors consistent with personal- ity disorders often overlap with other mental disorders, they may not be diagnosed when they have occurred only during the course of a separate disorder.
Cluster A Personality Disorders are disorders that tend to disrupt the individual’s ability or desire to connect or develop relationships with others as a result of fearful or delusional thoughts, or a desire to withdraw. Paranoid Personality Disorder is characterized by the belief that others in the person’s life may desire or be planning harm, lead- ing to behaviors of suspicion and reluctance to trust others, includ- ing romantic and close relationships. Schizoid Personality Disorder, on the other hand, is characterized by aloof interpersonal behaviors and apparent lack of emotional expression. Individuals with this dis- order often have few social interests, a lack of close friends, and do not seek close relationships or sexual experiences. Schizotypal Personal- ity Disorder is different from Schizoid Personality Disorder in that the deficits in relationships are more related to thought difficulties such as misperceptions during social interactions, odd beliefs and unusual experiences, as well as excessive and externally focused social anxiety or paranoia.
Cluster B Personality Disorders tend to disrupt the individual’s ability to establish or maintain relationships because of an intrusive and self-centered pattern of behaviors within relational contexts or
Co py
ri gh
t Am
er ic
an P sy
ch ol og ic al A ss oc ia ti on . No t fo r fu
rt he
r di
st ri
bu ti
on .
100 C h e r r y e t a l .
across social areas. Antisocial Personality Disorder is characterized by a generalized willingness to harm others and a pattern of lack of concern for the well-being of others. Behaviors within this disorder can include a pattern of legal infractions, putting others or self at risk of harm, interpersonal violence or theft, lying or consistently failing to follow fair expectations of work or financial duties, and apparent lack of guilt or shame in these behaviors. Individuals with Antisocial Personality Disorder must be at least 18 but must have shown signs of meeting the criteria of conduct disorder prior to age 15. Borderline Personal- ity Disorder is distinguished by a pattern of unstable interpersonal relationship behaviors that are related to instability in the individual’s self-image and emotions. These may be extreme, often occur in the context of close relationships, and seem focused on polar (very positive and very negative) views of others. These individuals vacillate between extremely oversolicitous behavior and anger outbursts in relation- ships. Impulsivity, self-harmful behavior, and threats may be involved in eliciting relational help. Histrionic Personality Disorder is marked by strong behaviors of attention-seeking and extreme emotional dis- plays, including sexually or emotionally provocative displays toward others. Narcissistic Personality Disorder denotes a significant and sustained difficulty in interpersonal behavior in which the person is self-centered and focuses on his or her importance at the expense of concern or compassion for others. Individuals with this disorder are often unrealistic in their positive self-beliefs and ways they think others see them.
Cluster C Personality Disorders differ widely in terms of inter- personal behavior but seem to all have a goal of anxiety reduction related to negative beliefs about self. Individuals with Avoidant Per- sonality Disorder have strong feelings of inadequacy and fear criti- cism or negative assessment from others. As a result, they tend not to engage in relationships, activities, or social behavior that could potentially expose them to ridicule or negative feelings. Dependent Personality Disorder, by contrast, is representative of individuals who consistently engage in attempts to get others to take care of them and may even demonstrate self-deprecating behaviors to maintain this help. They may feel incapable of self-managing or being safe without the constant support and approval in most or all areas of their lives. Obsessive–Compulsive Personality Disorder is marked by thoughts and behaviors that are disruptive to the individual’s daily functioning but seem focused on rigid and uncompromising control of the self, others, and the environment. This apparent rigidity and need for control appear in behavior in many forms, such as moral and behavioral per- fectionism and fixation on environmental and personal issues, such as
Co py
ri gh
t Am
er ic
an P sy
ch ol og ic al A ss oc ia ti on . No t fo r fu
rt he
r di
st ri
bu ti
on .
101Psychopathology and Use of the Diagnostic and Statistical Manual
cleanliness, orderliness, and complete consistency in daily behaviors and interactions with others. Individuals with Obsessive-Compulsive Disorder may also demonstrate a rigid attachment to objects, money, self-managing tasks, and ideas.
Paraphilic Disorders
Paraphilia is defined as an intense and persistent sexual interest other than interest in preparatory fondling or genital stimulation with pheno- typically normal, physically mature, consenting humans. Paraphilias primarily concern an individual’s erotic activities or the erotic targets. In all of the following paraphilic disorders, two criteria must be met. The first (Criterion A) specifies the qualitative nature of the paraphilia, and the second (Criterion B) specifies the negative consequences of the paraphilia. The diagnosis should be used only when an individual meets both criteria.
Common classification themes group the disorders within the para- philic disorders. The first group is based on anomalous activity pref- erences and has subdivisions of courtship disorders (those resembling distorted components of human courtship behaviors) and algolagnic disorders (those that involve pain and suffering). Within the courtship subdivision, Voyeristic Disorder (spying on others in private activities), Exhibitionistic Disorder (exposing the genitals), and Frotteuristic Dis- order (touching or rubbing against a non-consenting individual) are included. The algolagnic disorders include Sexual Masochism (under- going humiliation, bondage, or suffering) and sexual sadism (inflicting humiliation, bondage, or suffering). The second group of disorders is based on anomalous target preferences, which include those directed at other humans and elsewhere. Pedophilic Disorder consists of 6 months or longer of recurrent intense sexually arousing fantasies, sexual urges, or behaviors involving sexual activity with a prepubescent child. Fetishistic Disorder consists of recurrent and intense sexual arousal from either the use of nonliving objects or a highly specific focus on non-genital body parts. Transvestic Disorder is described as a recurrent and intense sexual arousal from cross-dressing that is manifested by fantasies, urges, or behaviors. Finally, Other Specified Paraphilic Disor- der and Unspecified Paraphilic Disorder can be used when a presenta- tion of symptoms characteristic of a paraphilic disorder cause distress or impairment in social, occupational, or other areas of functioning, but full criteria for a paraphilic disorder are not met. More specifically Other Specified Paraphilic Disorder is used when the clinician chooses
Co py
ri gh
t Am
er ic
an P sy
ch ol og ic al A ss oc ia ti on . No t fo r fu
rt he
r di
st ri
bu ti
on .
102 C h e r r y e t a l .
to communicate the reason for the presentation not meeting full crite- ria for a paraphilic disorder, whereas, Unspecified Paraphilic Disorder is used when the clinician chooses not to specify the reason that full criteria are not met.
Cultural Formulation
Although the authors of the DMS–5 make explicit the need to consider cultural explanations and issues in diagnosis and treatment of mental disorders, Section III: Emerging Measures and Models, gives consider- ation to specific ways of assessing and understanding the influence of culture. The term culture is seen as the full context, environment, and history of the individual, with an attempt to understand the influences on how he or she thinks, self-reflects, behaves, and relates to others over time, as well as the way this is transmitted to generations over time within a group. Culture can include the individual’s economic background and resources, religion, ethnicity, race, language, world- view, educational milieu, and family structure, among other things. Psychologists have a special need to carefully consider the influence of experience and context on the whole person when diagnosing or try- ing to treat patients. The authors have provided an interview for clini- cal practice use titled “Cultural Formulation Interview,” with forms for conducting it with both patients and informants. This interview assesses several components of the individual being diagnosed and treated and the factors of culture that may affect treatment focus and structure. The Cultural Formulation section continues and provides the out- line recommended by the authors for formulating the diagnosis and treatment plan based on a more full cultural understanding, includ- ing consideration for the patient’s self-understood cultural identity, the relationship between the patient and his or her cultural experience and support, and the relationship between the patient and the provider. One of the strengths of this section is the authors’ goal to affect every patient–provider encounter. The provider of assessment and treatment should consider the importance of culture for every patient, regardless of whether the provider believes he or she shares the culture of the patient because assumptions within a group may be as detrimental to accurate diagnosis and treatment formulation as when the apparent cultures differ. An example would be Sam, a 24-year-old White male middle manager with a business degree, raised within a deeply racist community, coming to you dealing with anxiety, poor relations with employees under his supervision, and work-related stress because he is in a highly racially heterogeneous factory. A cultural formulation could
Co py
ri gh
t Am
er ic
an P sy
ch ol og ic al A ss oc ia ti on . No t fo r fu
rt he
r di
st ri
bu ti
on .
103Psychopathology and Use of the Diagnostic and Statistical Manual
significantly help in understanding the origins of his feelings, provide a framework for therapy goals, and minimize the chance that the thera- pist would create barriers to engagement and support.
Application and Practice
The following exercises are intended to assist in the application of diag- nostic decision making and material from this chapter. Throughout the two exercises, as well as when you apply the material from this chapter and DSM–5 to clinical practice, we encourage you to keep in mind and discuss with your supervisor the following questions and considerations.
Consider the cultural context related to the patient’s present- ing issues—is this a problem within his or her culture? Is the prob- lem related to difficulties acculturating to the dominant culture? Is the patient reacting expectedly to his or her environment? Are there problems in the family system to which we can attribute the develop- ment, maintenance, or exacerbation of problematic thoughts or behav- iors? Are there recent stressors involved, such as a death in the family, change in or loss of job, or change in schools?
Use a developmental perspective in conceptualizing your case. Is the target behavior appropriate for the patient’s given age (chrono- logical or mental)? Given the patient’s age, what factors do we consider to be important in diagnosing or conceptualizing the case? Is the prob- lem related to aging? How might the presenting problem have started? Where is it likely to progress if we do not do anything?
Use an assessment-driven or clinical hypothesis–driven treatment approach. Keep in mind possible etiological or other factors that may contribute to or maintain target cognitions or behaviors. What factors do we believe contribute to the given problem? How do we assess those factors in a meaningful way? Are there any evidence-based assessments that can serve these purposes with this given patient in this particular context? Who could we ask to provide more information about the pre- senting concern? A spouse? Teacher? Grandparent? More perspectives can help you form a complete picture of the situation (but don’t get carried away and expect varying opinions and conflicting data to arise). What assessment modalities might we use to gather clinical data? Stan- dardized pencil-and-paper measures? Observations? Projective tests? Structured diagnostic interviews?
Are there operating interpersonal factors at play? Has the client mentioned recent peer or coworker relational problems? Has there been a recent breakup or divorce with a significant other? What was the client’s early childhood like? How might those early patterns of
Co py
ri gh
t Am
er ic
an P sy
ch ol og ic al A ss oc ia ti on . No t fo r fu
rt he
r di
st ri
bu ti
on .
104 C h e r r y e t a l .
interactions influence present interpersonal functioning? Did a friend move away? Is the patient grieving the loss of someone?
Vignette 1: “Mikey”
Mikey is a 6-year-old boy who was brought to the psychology clinic by his mother due to behavior problems. Mikey’s mother wants to know whether his behavior problems are worse than those of other kids or whether she is overreacting. Her husband, Mikey’s stepfather, thinks Mikey is “just being a boy” and that all he needs is “a good whoopin’.” Mikey’s mother doesn’t know what else to do, and she wants help getting Mikey’s behavior under control before he gets kicked out of school. After prompting for more specific information related to Mikey’s reported behavior problems, his mother reported Mikey will say “No!” when she asks him to “clean up” or “get ready.”
QUESTIONS TO CONSIDER
Disruptive behavior is one of the most common referral problems in clinical work with children. A multitude of factors can lead to child behavior problems, including impulsivity caused by ADHD, moodiness caused by depression, or anxiety related to social situations or trauma. The following information will be helpful in determining an appropri- ate diagnosis and treatment plan:
❚❚ What additional information do we need to determine a diagnosis? ❚❚ When did these behavioral problems start? Did they begin after a major stressor, trauma, life event, or change in the family environ- ment or structure? Or has he always had a “difficult” temperament?
❚❚ Do these behaviors present throughout the day or at specific times (before school, at dinner, at bedtime)?
❚❚ Are there any concerns related to physical abuse in this situation? What do you do if you suspect abuse?
❚❚ What is Mikey’s behavior like at school and with other adults? Is he defiant with his teacher as well as his mother? How is his behavior with his stepfather?
❚❚ How is Mikey behaving in the clinic? How does he respond to attention from you? Does he appear nervous or angry?
❚❚ What is Mikey’s home life like? Who lives at home with him? Does he have siblings with similar behavioral concerns?
❚❚ What’s Mikey’s typical mood like? Is he often irritable or sad? ❚❚ What happens after Mikey says “No!” or is defiant? Does he get out of any unwanted situations, like cleaning up?
Co py
ri gh
t Am
er ic
an P sy
ch ol og ic al A ss oc ia ti on . No t fo r fu
rt he
r di
st ri
bu ti
on .
105Psychopathology and Use of the Diagnostic and Statistical Manual
Vignette 2: “Leon”
Leon is a 60-year-old veteran who served in the U.S. Army during the Vietnam War. He was referred to the psychology clinic by his VA pri- mary care provider, who reports presenting concerns including irritabil- ity, medical nonadherence, and chronic back pain that the primary care provider believes is not fully explained by medical problems. Leon and his provider (the fifth provider he has had in 5 years) disagree about whether he should be prescribed opioid painkillers to help him cope with his back pain. Leon says his medications work best when he has “a few” alcoholic drinks to “wash them down.” The veteran says he cannot work and has limited mobility because of his back pain and demands that you help him get more service-connection pay from the VA. When you ask about Leon’s sleep, he laughs and says, “haven’t slept since ‘Nam.” He then becomes quiet and distracted.
QUESTIONS TO CONSIDER
Often, medical professionals will refer patients to psychology profes- sionals with specific concerns and proposed plans of action in mind. Clinicians can be placed in a precarious position in which they are bal- ancing the needs and perceived goals of the patient with the perceived goals of the physician (who may decide not to refer to them in the future). Clinicians can be placed in a precarious position where they are balancing the needs and perceived goals of the patient with the perceived goals of the physician (who may decide not to refer to you anymore). On the one hand, the physician is focused on the threat of prescription painkiller abuse. On the other hand, the veteran believes he is being ignored and is tired of being abused by “the system.”
❚❚ What possible factors are contributing to Leon’s irritability? Sleep? Medication or substance withdrawal? Trauma-related symptoms of hyperarousal? Chronic pain?
❚❚ What impact has the veteran’s military service had on his percep- tions of himself and others? Does he trust his doctor or you? Does he trust his own judgment?
❚❚ What effect can alcohol have on Leon’s sleep, trauma symptoms, medications, and interpersonal and occupational functioning?
❚❚ How might stress and negative emotions influence Leon’s percep- tion of pain?
❚❚ What should your target of treatment be? What forms of treat- ment would be most acceptable to the patient? Would he do well in a group setting or an individual setting? How should you present possible treatment options to Leon to gain buy-in?
Co py
ri gh
t Am
er ic
an P sy
ch ol og ic al A ss oc ia ti on . No t fo r fu
rt he
r di
st ri
bu ti
on .
106 C h e r r y e t a l .
Diagnostic decision making and treatment planning are complex processes. The case vignettes and application questions provided here are opportunities to practice applying diagnostic decision making, includ- ing use of the diagnostic criteria listed in the DSM–5, as well as con- sidering the cultural context, developmental stage, assessment-driven or clinical hypothesis–driven treatment approaches, and interpersonal factors relevant to each individual. These case vignettes and applica- tion questions should also provide opportunities for discussions with your supervisor(s) to assist in making the information provided in this chapter meaningful in your growth as a future professional in the field of psychology.
References
American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders (4th ed.). Washington, DC: Author.
American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed., text rev.). Washington, DC: Author.
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author.
American Psychiatric Association. (2014a). DSM: History of the man- ual. Retrieved from http://www.psychiatry.org/practice/dsm/DSM- history-of-the-manual
American Psychiatric Association. (2014b). Understanding ICD–10–CM and DSM–5: A quick guide for psychiatrists and other mental health clinicians. Retrieved from http://www.dsm5.org/Documents/Understanding%20 ICD%2002-21-14%20FINAL.pdf
American Psychological Association. (2009). ICD vs. DSM. Monitor on Psy- chology, 40, 63. Retrieved from http://www.apa.org/monitor/2009/10/ ICD-dsm.aspx
Doherty, J. L., & Owen, M. J. (2014). The Research Domain Criteria: Moving the goal posts to change the game. The British Journal of Psy- chiatry 204, 171–173.
Grob, G. N. (1991). Origins of DSM–I: A study in appearance and reality. The American Journal of Psychiatry, 148, 421–431.
Houts, A. C. (2000). Fifty years of psychiatric nomenclature: Reflec- tions on the 1943 War Department Technical Bulletin, Medical 203. Journal of Clinical Psychology, 56, 935–967.
Stein, D., Lund, C., & Nesse, R. (2013). Classification systems in psy- chiatry: Diagnosis and global mental health in the era of DSM–5 and ICD–11. Current Opinions in Psychiatry, 26, 493–497.
World Health Organization (2010). International classification of diseases (10th revision). Geneva, Switzerland: Author. Retrieved from http:// www.who.int/classifications/icd/en
Co py
ri gh
t Am
er ic
an P sy
ch ol og ic al A ss oc ia ti on . No t fo r fu
rt he
r di
st ri
bu ti
on .
