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CHAPTER FOUR. Classification of Abnormal Behavior. DSM. DSM. Classification. Classification (what it is and why we do it) Classification systems Description of the DSM-IV Evaluation of the DSM-IV Limitations of DSM-IV. YOU ARE NOT RESPONSIBLE FOR THE ASSESSMENT SECTION. Classification.

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CHAPTER FOUR

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Chapter four

CHAPTER FOUR

Classification of Abnormal Behavior

DSM

DSM


Classification

Classification

  • Classification (what it is and why we do it)

  • Classification systems

  • Description of the DSM-IV

  • Evaluation of the DSM-IV

  • Limitations of DSM-IV

YOU ARE NOT RESPONSIBLE FOR THE ASSESSMENT SECTION


Classification1

Classification

  • Classification (what it is and why we do it)

  • Classification systems

  • Description of the DSM-IV

  • Evaluation of the DSM-IV

  • Limitations of DSM-IV


What is classification

What is classification?

  • Classification

    • subdividing or organizing a set of related objects

  • Animals, Historical Periods, and Music are subdivided and organized in various ways


Why use a classification system

Why use a classification system?

  • Benefit

    • a shared scientific language

      • facilitates description

      • aids treatment decisions, prognosis

      • facilitates research on etiology, treatment outcome

      • facilitates 3rd-party reimbursement (managed care system)


Why use a classification system1

Why use a classification system?

  • Concerns

    • stigmatization and marginalization

    • expectations for behavior may change as result

    • unrelated problems may be misattributed to diagnosis

Rosenhan’s Study


Classification2

Classification

  • Classification (what it is and why we do it)

  • Classification systems

  • Description of the DSM-IV

  • Evaluation of the DSM-IV

  • Limitations of DSM-IV


Describing classification systems

DIAMOND

COAL

Describing Classification Systems

What do the items in each group have in common?

1

2

Stroke Heart Attack

3


Categories vs dimensions

Categories vs. Dimensions

  • Categorical Approach

    • reflects a difference in kind or quality

  • Dimensional Approach

    • focuses on the amount of a particular characteristic an object possesses

HEIGHT


Approaches to classifying abnormal behavior

not depressed | depressed

Approaches to Classifying Abnormal Behavior

  • Categorical Approach

    • people with abnormal behaviors are qualitatively different from normal people (discrete groups)


Are you depressed

Are you Depressed?

  • Yes

  • No


Chapter four

Categorical Approach


Approaches to classifying abnormal behavior1

very depressed

mildly depressed

not at all depressed

Approaches to Classifying Abnormal Behavior

  • Dimensional Approach

    • people with abnormal behaviors are quantitatively different (continuum)

X = ?


How depressed are you

How Depressed are you?

Not at all Extremely

0

1

2

3

4


Chapter four

very depressed

mildly depressed

not at all depressed

Approaches to Classifying Abnormal Behavior

  • Threshold Approach

    • combines categorical and dimensional

X


How depressed are you1

How Depressed are you?

Not at all Extremely

0

1

2

3

4

Legend:

0-1 = Not Depressed

2 and above = Depressed


Classification3

Classification

  • Classification (what it is and why we do it)

  • Classification systems

  • Description of the DSM-IV

  • Evaluation of the DSM-IV

  • Limitations of DSM-IV


Chapter four

Description of DSM-IV System

  • Depends on observations and descriptions, rather than causes, which are often unknown

  • Categorical

  • Multi-Axial


Chapter four

Description of DSM-IV System

  • Axis I -- Clinical disorders

    • mostly characterized by episodic periods of psychological turmoil

  • Axis II -- Personality disorders and mental retardation

    • mostly concerned with stable, longstanding problems


Chapter four

Description of DSM-IV System

  • Axis III -- General Medical Conditions

    • conditions relevant to etiology of patient’s behavior or treatment program

  • Axis IV -- Psychosocial & EnvironmentalProblems

    • factors that may affect the treatment and prognosis of mental disorder


Chapter four

Description of DSM-IV System

  • Axis V -- Global Assessment of Functioning

    • rating of 1 to 100 of individual’s overall level of functioning

    • usually assessed at several points

      • highest in last year

      • at intake

      • Current

        The only axis that is dimensional


Chapter four

  • 90 -100

    • Superior functioning in a wide range of activities, life’s problems never seem to get out of hand, is sought out by others because of his or her many positive qualities. No symptoms

  • 51-60

    • Moderate symptoms (e.g., flat affect and circumstantial speech, occasional panic attacks) OR moderate difficulty in social, occupational, or school functioning (e.g., few friends, conflicts with peers or co-workers)

  • 1-10

    • Persistent danger of severely hurting self or others (e.g., recurrent violence) OR persistent inability to maintain minimal personal hygiene or serious suicidal act with clear expectation of death


Dsm iv tr hypothetical example

DSM-IV TR: Hypothetical Example

Axis I: Major Depression, Recurrent, Mild

Axis II: No diagnosis, frequent use of denial

Axis III: Recurrent ear infections

Axis IV: Victim of child neglect, 3 younger sibs

Axis V: GAF = 56 (current)

Remember Gary?


Dsm iv a 5 axis system

DSM-IV: A 5-Axis System

The Case of “Gary”

Axis I: R/O Major depressive disorder

Axis II: Schizoid personality disorder

Axis III: Arrhythmia

Axis IV: Problems related to the social environment

Axis V: 60 (current)


Hypothetical example 2

Hypothetical Example 2

specifiers

Rule out

Axis I: Major Depression, Recurrent, Mild        Alcoholism, in remission

Bulimia Nervosa (provisional)

Axis II: R/O Borderline Personality Disorder

Axis III: Ovarian Cancer

Axis IV: sexually abused as a child, rape-victim

Axis V: GAF = 45 (at intake)


Classification4

Classification

  • Classification (what it is and why we do it)

  • Classification systems

  • Description of the DSM-IV

  • Evaluation of the DSM-IV

  • Limitations of DSM-IV


Evaluation of dsm iv

Evaluation of DSM-IV

  • Reliability

    • consistency of

      measurements, including

      diagnostic decisions

Reliability

Test

Clinician

Observed/Predicted Outcome

Test score or performance

Diagnosis


Evaluation of dsm iv1

Evaluation of DSM-IV

  • Inter-rater Reliability

    • refers to agreement of raters about observations


Chapter four

Evaluation of DSM-IV

  • Validity

    • meaning or importance of a classification system

    • conceptualized as a continuum of more to less useful (i.e., classification systems are more to less valid)

    • But valid for what?

      • We need to ask… how meaningful is it for a desired purpose?

      • Is the SAT valid?

        • (if we’re assessing aptitude, not artistic abilities)


Chapter four

1

2

3

Reliable and Valid?

LARRY

CURLY

MO


Chapter four

Validity Illustration

Cook Book B

Apple Pie:

apples, tomatoes, lettuce, flour

Burritos:

beans, cinnamon, tortillas, sugar

Cook Book A

Apple Pie:

apples, sugar, flour, cinnamon

Burritos:

beans, tortillas, tomatoes, lettuce


Chapter four

ICD10-DCR

A. Exposure to stressor

B. Persistent remembering of the stressor in one of: intrusive flashbacks, vivid memories or recurring dreams, experiencing distress when reminded of the stressor

C. Requires only onesymptom of actual or preferred avoidance

Either of D1 orD2:

D1 inability to recall

D2 two or more of:

A. sleep problems

B. Irritability

C. concentration problems

D. Hypervigilance

E. exaggerated startle response

E. Onset of symptoms within 6 months of the stressor

DSM-IV

A1. Exposure to stressor

A2. Emotional reaction to stressor

Requires one or more of:

B1. Intrusive recollections

B2. Distressing dreams

B3. Acting/feeling as though event were recurring

B4. Psychological distress when exposed to reminders

B5. Physiological reactivity when exposed to reminders

Requires three or more symptoms of:

C1. avoidance of thoughts, feelings or conversations associated with the stressor

C2. avoidance of activities, places or people associated with the stressor

C3. inability to recall

C4. diminished interest in significant activities

C5. detachment from others

C6. restricted affect

C7. sense of foreshortened future

Two or more of:

D1. sleep problems

D2. irritability

D3. concentration problems

D4. hypervigilance

D5. exaggerated startle response

E. Duration of the disturbance is at least 1 month

F. Requires distress or impairment

PTSD


Chapter four

Validity & Evaluation of DSM-IV

  • Types of Validity

    • Etiological

    • Concurrent

    • Predictive


Chapter four

Validity & Evaluation of DSM-IV

  • Etiological Validity

    • concerned with the specific factors that are regularly and perhaps uniquely associated with a particular disorder


Etiological validity

Etiological Validity

Classification System 1

Cause Disorder

A A1

B B1

C C1

D D1

Classification System 2

Cause Disorder

A A1

B B1

C C1

D D1


Chapter four

Validity & Evaluation of DSM-IV

  • Concurrent Validity

    • concerned with the present time and the association between disorder and other symptoms, life events and test performance


Chapter four

Validity & Evaluation of DSM-IV

  • Predictive Validity

    • concerned with the accuracy of predictingfuture treatment and treatment outcomes


Classification5

Classification

  • Classification (what it is and why we do it)

  • Classification systems

  • Description of the DSM-IV

  • Evaluation of the DSM-IV

  • Limitations of DSM-IV


Limitations of the dsm iv

Limitations of the DSM-IV

  • Arbitrary boundary between normal and abnormal behavior

    • Cutoff points not always empirically justified

    • Reliance on clinicians’subjective judgment

    • Time periods in definitions of diagnoses


Chapter four

Limitations of the DSM-IV

  • Problem of Comorbidity

    • Simultaneous appearance of two or more disorders in the same person

    • 56% of those who meet criteria for one disorder also meet criteria for at least one other disorder

    • Comorbidity affects validity of the system and the reliability of diagnosis


Last word on classification for now

Last Word on Classification(for now)

  • Beware of “Intern's Syndrome”

    Tendency to diagnose one's self while studying any particular disorder (“I do that!”)

    • look at frequency and severity of symptoms, as well as number of symptoms

    • check in with friends and or professionals about how you're doing


Optional slides

Optional Slides


Chapter four

Categorical Approach


Chapter four

Categorical Approach


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