Utilization of the DSM-IV

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Hi,

Let's take a closer look at these interesting questions!

1. How does the DSM-IV explain people's behavior and what are the assumptions about human behavior?

BACKGROUND ON DSM -IV

First, let's look at some background information. There are two diagnostic approaches to diagnostic psychopathology. The first is called descriptive because diagnoses are based on relatively objective phenomena that require nominal clinical inference; these phenomena include signs, symptoms, and natural history (DSM-IV). The second is called psychological because diagnoses are based primarily on inferred causes and mechanisms (DSM-I). The psychological approach also considers descriptive phenomena, but as merely superficial manifestations of more profound underlying forces.

The descriptive approach focuses on the "what" of behavior (DSM-IV), the psychological on its "why." Amy's case (read attachment) illustrates the common mistake of confusing the two. What was wrong (major depression) had been ignored because people focused on why things were wrong (having cancer and a mastectomy). Failing to distinguish the "what" from the why of psychopathology is a novice's big mistake. An example: A hallucinating, disheveled youth, convinced he was Jesus Christ, told beginning medical students that he parents shifted his creativity, poisoned his food, and stole his Nintendo. Once he left the room, the students were asked, "What do you think is wrong with him?" "Nothing," they replied, "the problem is that he has lousy parents." Yet, even assuming he has dreadful parents (the why), he is no less delusional and hallucinatory (the what).

Both descriptive and psychological approaches are valuable, since each addresses a different aspect of psychopathology. Take a delusion. The descriptive approach would detail its characteristics: Is it fixed? Vague? Paranoid? Circumscribed? The psychological approach would focus on inner mechanisms (e.g., projection), which produce the delusion.

Until DSM-III (1980), the psychological approach dominated American psychiatry, largely because it dovetailed with Freudian thought, which has always enjoyed more popularity in the United States than anyplace else. Diagnoses were based on psychoanalytic criteria, such as "poor ego boundaries," "oral regression," "polymorphous perversity," "projection," and "primary process." The more psychiatrists focused on these inferred phenomena, the more they recognized that everybody had them to various degrees. This helps explain three differences between psychological and descriptive diagnoses.

1. The psychological view holds that, as a price for civilization, everyone has some degree of psychopathology; with the descriptive approach, only a minority has psychopathology.

2. Psychologically-derived diagnoses follow a unitary model, in which there is essentially one mental disorder, whose name is a matter of degree, not type-from the last severe to the most: neuroses, personality disorders, manic-depression, and schizophrenia. As in physical medicine, the descriptive approach follows a multiple-model, in which disorders are distinct and numerous.

3. The psychological view considers patients to have more severe psychopathology than does descriptive view. Patients diagnosed, as "neurotic" by psychological criteria might have "no mental disorder" by descriptive criteria, whereas those diagnosed as "schizophrenia" by psychological criteria might be diagnosed as "manic" or "depressive" by descriptive criteria (Maxmen & Ward, 1997).

DSM IV (1994) continues the descriptive approach of DSM-III and DSM III-R (1987). Because DSM-IV criteria (e.g., decrease in appetite, insomnia) are relatively objective and explicit, they are far easier for clinicians to identify and agree on; in contrast, DSM-II's inferred psychological mechanism (e.g., internal conflict) produces a much lower interrater reliability. Whether or not DSM-IV criteria for a major depression are optimal or valid can be disputed; yet because they are precise, when a therapist states the "patient X meets DSM-IV criteria for major depressive disorder," clinicians know what is meant.

Despite the exactness of DSM-IV criteria, however, their application still necessitates clinical judgment. In criterion "A" (see online DSM-IV-TR classification http://behavenet.com/capsules/disorders/dsm4TRclassification.htm) for depressive episode, for instance, how much sleep loss (#4) constitutes "insomnia"? How much diminished interest or pleasure is "marked" (#2)? In practice, as clinicians gain experience, they develop internal norms to answer such a questions. In addition, both recent history-e.g., two-week ...