Topic 3: CLASSIFICATION AND ASSESSMENT OF ABNORMAL BEHAVIOR

Learning Objectives:

At the end of this chapter, you should be able to:

• Identify and appreciate the significance, benefits, and limitations of diagnostic and statistical
manual of mental disorders.

• Apply the knowledge learned in this chapter for sample cases of psychological disorders.
 Clinical Case: Aaron

Hearing the sirens in the distance, Aaron realized that someone must have called the police. He didn’t mean to get upset with
the people sitting next to him at the bar, but he just knew that they were talking about him and plotting to have his special
status with the CIA revoked. He could not let this happen again. The last time people conspired against him, he wound up in the
hospital. He did not want to go to the hospital again and endure all of the evaluations. Different doctors would ask him all sorts
of questions about his work with the CIA, which he simply was not at liberty to discuss. They asked other odd questions, such
as whether he heard voices or believed others were putting thoughts into his head. He was never sure how they knew that he
had those experiences, but he suspected that there were electronic bugging devices in his room at his parents’ house, perhaps
in the electrical outlets.

Just yesterday, Aaron began to suspect that someone was watching and listening to him through the electrical outlets. He
decided that the safest thing to do was to stop speaking to his parents. Besides, they were constantly hounding him to take his
medication. But when he took this medication, his vision got blurry and he had trouble sitting still. He reasoned that his parents
must somehow be part of the group of people trying to remove him from the CIA. If he took this medication, he would lose his
special powers that allowed him to spot terrorists in any setting, and the CIA would stop leaving messages for him in phone
booths or in the commercials on Channel 2. Just the other day, he found a tattered paperback book in a phone booth, which he
interpreted to mean that a new assignment was imminent. The voices in his head were giving him new clues about terrorist
activity. They were currently telling him that he should be wary of people wearing the color purple, as this was a sign of a
terrorist. If his parents were trying to sabotage his career with the CIA, he needed to keep out of the house at all costs. That
was what had led him to the bar in the first place. If only the people next to him wouldn’t have laughed and looked toward the
door. He knew this meant that they were about to expose him as a CIA operative. If he hadn’t yelled at them to stop, his cover
would have been blown.
Introduction

Diagnosis and assessment are the critically important “first steps” in the study and treatment of
psychopathology. In the case of Aaron, a clinician may begin treatment by determining whether Aaron
meets the diagnostic criteria for a mood disorder, schizophrenia, or perhaps a substance-related disorder.
Diagnosis can be the first major step in good clinical care. Having a correct diagnosis will allow the clinician
to describe base rates, causes, and treatment for Aaron and his family, all of which are important aspects of
good clinical care.

Diagnosis enables clinicians and scientists to communicate accurately with one another about cases or
research. Without agreed-on definitions and categories, our field would face a situation like the Tower of
Babel (Hyman, 2002), in which different scientists and clinicians would be unable to understand each other.

Diagnosis is important for research on causes and treatments. Sometimes researchers discover unique
causes and treatments associated with a certain set of symptoms. For example, autism was only recognized
in the Diagnostic and Statistical Manual in 1980. Since that time, research on the causes and treatments of
autism has grown exponentially.
DIAGNOSIS AND CLINICAL ASSESSMENT

What is a Diagnosis (Dx)?

It is the label or name given for a syndrome.

Syndrome defined:

(1) Disease or disorder that involves a particular group of signs and symptoms. (Merriam-Webster)
(2) A collection or set of signs and symptoms that characterize or suggest a particular disease.
(3) Combination of signs and symptoms.

Signs- are objective observation of the syndrome by a physician or clinician; signs are visible externally.
(e.g. weight loss, skin rash)

Symptoms- are subjective. It is the patient’s observation of the syndrome. It can only be described by
the person feeling them. (e.g. pain, dizziness, numbness, fatigue, vision disturbance, lightheadedness)
Why is diagnosis important?

(1) It allows the clinician to describe base rates, causes, and treatment

(2) Often, a diagnosis can help a person begin to understand why certain symptoms are occurring, which
can be a huge relief.

(3) It enables clinicians and scientists to communicate accurately with one another about cases or research.

(4) It is important for research on causes or treatments.

Disease vs. Disorder

Disease- resulting from a pathophysiological response to external or internal factors. It is mostly:

(1) Organic in nature or has an organic cause

(2) Observed because of structural changes to patients. Physical changes may be seen in patients.

(3) Can be confirmed through laboratory tests.

Disorder- a disruption to the normal or regular functions in the body or a part of the body. The effect of disorder
is mostly:

(1) Functional; there is an interference with the person’s daily life (e.g. to hold a job or form relationships.)

(2) The detection of a disorder is dependent to the symptoms.

(3) Not confirmed by laboratory tests.

Clinical Assessment

• Is the process of collecting information about an individual for understanding and arriving at
an informed decision.

• It is a systematic evaluation and measurement of psychological, biological, and social factors

in an individual presenting with a possible psychological disorder.
Cornerstones of Diagnosis and Assessment

Three basic concepts that help determine the value of clinical assessments:

(1) Reliability

(2) Validity

(3) Standardization
Reliability- is the degree to which a measurement is consistent; producing same results.

Types of reliability that is most central to assessment and diagnosis:

(1) Interrater Reliability- degree to which two independent observers agree on what they have observed.

(2) Test-retest Reliability- extent to which people being observed twice or taking the same test twice,
perhaps several weeks or months apart, receive similar scores. Note: This only makes sense when we can
assume that people will not change appreciably between test sessions on the underlying variable being
measured.

(3) Alternate-form reliability- extent to which scores on the two forms of the test are consistent.

(4) Internal consistency reliability- assesses whether the items on a test are related to one another. (e.g.
items in an anxiety inventory should be interrelated, or correlated with one another, if they truly tap
anxiety.)
Validity- related to whether a measure measures what it is supposed to measure. (e.g. If a questionnaire is
supposed to measure a person’s hostility, does it do so?)

NOTE: Validity is related to reliability—unreliable measures will not have a good validity.

Types of Validity:

(1) Content Validity- refers to whether a measure adequately samples the domain of interest.

(2) Criterion Validity- evaluated by determining whether a measure is associated in an expected way with
some other measure (the criterion).

✓ Concurrent validity- if both variables are measured at the same point in time.
✓ Predictive validity- assessed by evaluating the ability of the measure to predict some other variable that
is measured at some point in time in the future.

(3) Construct Validity- viewed as an overarching concept that encompasses all other forms of validity.
Construct- is an idea of an attribute or characteristics inferred.
Standardization- process by which a certain set of standards or norms is determined for a
technique to make its use consistent across different measurements.

EXAMPLE: Your score on a particular psych test should be compared only to the norms of Asians
and not to the scores of different people, such as African-American males.
 CLASSIFICATION AND DIAGNOSIS

Classification System aka Nomenclature- set of definitions of syndromes and rules for determining when a
patient’s symptoms are part of each syndrome.

Classification Systems presently used by clinicians:

(1) Diagnostic and Statistical Manual of Mental Disorders 5th Edition by the American Psychiatric Association

(2) International Statistical Classification of Diseases and Related Health Problems (ICD-10) by the World Health
Organization

2 Essential Strategies in the Study and Treatment of Psychopathology

(1) Idiographic Strategy- used to determine what is unique about an individual’s personality, cultural background,
or circumstances.

(2) Nomothetic Strategy- taking advantage of the information already accumulated on a particular problem or
disorder by determining a general class of problems to which the presenting problem belongs. In other words, we
are attempting to name or classify the problem.
Issues in Classification

1. The subject of classification becomes controversial in humans unlike classifications in the field of
biology or geology courses.

2. Some people have questioned whether it is proper or ethical to classify human behavior. (E.g.
the use of terms such as “normal” and “abnormal”)

3. Some would prefer to talk about behavior and feelings on a continuum from happy to sad or
fearful to non-fearful rather than to create categories as mania, depression, and phobia.
Ways of Classifying Human Behavior

(1) Categorical Approach or Classical (Pure)- originates in the work of Emil Kraepelin and the biological
tradition in the study of psychopathology. Here we assume that every diagnosis has a clear underlying
pathophysiological cause, such as bacterial infection or malfunctioning endocrine system, and that each
disorder is unique. A categorical system defines a threshold for treatment that helps demarcate a point
where treatment is recommended. Although the cutoffs are likely to be somewhat arbitrary, they can
provide helpful guidance. (e.g. Does the patient have schizophrenia or not?)

NOTE: Despite some debate, DSM-5 preserves a categorical approach to diagnosis. A dimensional approach
to personality traits has been included in the appendix, but other diagnoses are based on categorical
classification. As with DSM-IV-TR, the DSM-5 includes the category “unspecified” to be used when a person
meets many but not all of the criteria for a diagnosis.

NOTE: A categorical system forces clinicians to define one threshold as “diagnosable”. Categorical diagnoses
foster a false impression of discontinuity (Widiger, 2005). Indeed, up to half of the people seeking treatment
have mild symptoms that fall just below the threshold diagnosis. Many of these people with sub-threshold
symptoms of a diagnosis still receive extensive treatment.
(2) Dimensional Approach- describes the degree of an entity that is present (e.g. a 1-to-10 scale of
anxiety, where 1 represents minimal and 10, extreme).

(3) Prototypical Approach- identifies certain essential characteristics of an entity so that clinicians can
classify it but it also allows certain nonessential variations that do not necessarily change the
classification. When this is used in classifying psychological disorder, many possible features or
properties of the disorder are listed and any candidate must meet enough of them to fall into that
category.

Example: Consider diagnostic criteria defining a major depressive episode. The criteria include many
nonessential symptoms, but if you have either depressed mood or marked loss of interest or pleasure
in most activities and at least four of the remaining symptoms, you come close enough to the
prototype to meet the criteria for a major depressive episode.
One person might have:
(1) depressed mood
(2) significant weight loss
(3) insomnia
(4) psychomotor agitation
(5) loss of energy

Whereas, another person who also meets the criteria for major depressive episode might have:

(1) Marked diminished interest or pleasure in activities

(2) Fatigue
(3) Feelings of worthlessness
(4) Difficulty thinking or concentrating
(5) Ideas of committing suicide

NOTE: Although both have the requisite five symptoms that bring them close to the prototype, they
look different because they share only one symptom.
 CREATING A DIAGNOSIS/DIAGNOSTIC IMPRESSION

How does a clinician arrive at a diagnosis?

Requirements for diagnosis:

1. Minimum number of symptoms according to the DSM 5.

2. Minimum duration.
3. Clinical significance of the symptom that brings distress or cause impairment to the patient.

Levels of Disorders

• Sub-threshold- 1 or 2 requirements are not met.

• Sub-syndromal - number or duration of symptoms are lacking.
• Subclinical- symptoms do not cause clinically significant distress or impairment.

NOTE: Essentially, these terms are used interchangeably to refer to symptoms, not full-blown or not severe
enough. At times, all the symptoms are there but in “too mild form” to impair functioning.
The Diagnostic and Statistical Manual of Mental Disorders 5th Edition (DSM 5, 2013) Features:

1. Descriptive, not explanatory

2. Categorical vs Dimensional/Continuum

3. Atheoretical
What are the Sections of DSM-5?

Section I: DSM-5 Introduction/Use of Manual

Section II: Diagnostic Criteria and Codes

Section III: Emerging Measures and Models

Appendix
What are the innovations observed in DSM-5?

(1) Multiaxial system of diagnosis (DSM-IV-TR) has been removed. Now, diagnosis only includes the clinical
syndrome (or syndromes if co-morbid) and the general medical condition.

(2) There is an ICD/DSM harmony.

(3) Chapters are reorganized in this new edition to reflect patterns of comorbidity and shared etiology

(4) New Diagnoses- such as Disruptive Mood Dysregulation Disorder for children and adolescents who are falsely
labeled with Bipolar Disorder because no category seemed to fit their symptoms. They do not meet the full criteria
for mania (defining feature of bipolar). Other diagnoses include: Language Impairment Disorder, Premenstrual
Dysphoric Disorder, Somatic Symptom Disorder, and Illness Anxiety Disorder)

(5) Combining Diagnoses- some DSM-IV-TR diagnoses were combined because there is not enough evidence for
differential etiology, course, or treatment response to justify the labeling. Example: DSM-IV-TR dx of Substance
Abuse and Dependence are replaced in DSM-5 as Substance Use Disorder; Hypoactive Sexual Desire Disorder and
Female Sexual Arousal Disorder are replaced with Female Sexual Interest/Arousal Disorder.

(6) Present DSM puts greater emphasis on the influence of age, gender, and culture in diagnosis.
Use of the New DSM Manual

In the illustration, we can see that:

(1) DSM-5 combines Axes I-III which are: Mental Disorders, Medical Disorders, Other Medical
conditions that may be the focus of Clinical Attention

(2) Expanded V codes of the DSM and Z codes of ICD-10 can be used to determine contextual or
situational factors (Also, you may consider including the reason for visit, factors that affect the
diagnosis, prognosis, or treatment). It was intentionally changed to be more similar with other
classification systems such as the ICD.

(3) In noting disability or impairment, the World Health Organization Disability Assessment Schedule
2.0 (WHODAS 2.0), Section III is used (also included in the DSM-5 appendix of assessment measures).
Note: This is not required for a diagnosis.
How to write a correct DSM-5 diagnosis?

1. Determine the disorder that meets the criteria.

2. Write the name of the disorder.
3. Add any subtype or specifiers of the disorder.
4. Add the ICD-10 code found at the top of the diagnostic criteria (Starting October 2014, ICD-10 codes should be used)

REMEMBER! In case of multiple diagnosis or comorbidity, the principal diagnosis is listed first, followed by the other
diagnoses in descending order of clinical importance.
 CULTURAL CONCEPTS OF DISTRESS

❑ This formerly called Culture Bound Syndromes are ways that cultural groups experience, understand, and
communicate suffering, behavioral problems, or troubling thoughts and emotions (APA, 2013).

❑ The term culture bound was used to describe patterned behaviors of distress or illness whose phenomenology
appeared distinct from psychiatric categories and were considered unique to particular cultural settings.

3 Main Types of Cultural Concepts

(1) Cultural Syndromes- are clusters of symptoms and attributions that tend to co-occur among individuals in
specific cultural groups, communities, or contexts and that are recognized locally as coherent patterns of
experience.

(2) Cultural Idioms of Distress- are ways of expressing distress that may not involve specific symptoms or
syndromes, but that provide collective, shared ways of experiencing and talking about personal or social
concerns. (e.g. “nausog”)

(3) Cultural Explanations or Perceived Causes- are labels, attributions, or features of an explanatory model that
indicate culturally recognized meaning or etiology for symptoms, illness, or distress.
Why are Cultural Concepts important?

(1) To avoid misdiagnosis: Cultural variation in symptoms and in explanatory models associated with these
cultural concepts may lead clinicians to misjudge the severity of a problem or assign the wrong diagnosis
(e.g., unfamiliar spiritual explanations may be misunderstood as psychosis)

(2) To obtain useful clinical information: Cultural variations in symptoms and attributions may be associated
with particular features of risk, resilience, and outcome.

(3) To improve clinical rapport and engagement: “Speaking the language of the patient”

(4) To improve therapeutic efficacy: Cultural influences the psychological mechanism of disorder, which need
to be understood and addressed to improve clinical efficacy. For example, culturally specific catastrophic
cognitions can contribute to symptom escalation into panic attacks.

(5) To guide clinical research: Locally perceived connections between cultural concepts may help identify
patterns of comorbidity and underlying biological substrates.

(6) To clarify cultural epidemiology.

Examples of Culture Bound Syndromes

1. Amok- “murderous frenzy”, is a dissociative episode that is characterized by a period of depression

followed by an outburst of violent, aggressive, or homicidal behavior. Patients return to premorbid states
following the episode. It seems to be prevalent only among males. The term “amok” originated in
Malaysia, but similar behavior patterns can be found in Laos, Philippines, Polynesia (cafard or cathard),
Papua New Guinea, and Puerto Rico (mal de pelea), and among the Navajo (iich’aa).

Precipitants: Feelings of loss, shame, anger, or lowered self-esteem although specific triggers were very
diverse in nature and presentation.

2. Ataque de Nervios- is an idiom of distress principally reported among Latinos from the Caribbean, but
recognized among many Latin American and Latin Mediterranean groups. Commonly reported symptoms
include uncontrollable shouting, attacks of crying, trembling, heat in the chest rising into the head, and
verbal or physical aggression. A general feature of an ataque de nervios is a sense of being out of control.
3. Possession Syndrome- involuntary possession trance states are very common presentations of emotional
distress around the world.

4. Shenjing Shuairuo- “weakness of the nervous system”, is a translation and cultural adaptation of the term
“neurasthenia”, lack of nerve strength. It is a syndrome of lassitude, pain, poor concentration, headache,
irritability, dizziness, insomnia, and over 50 symptoms. (at about 87% of those who have this actually meets the
criteria of major depression.)

5. Koru- reported in South and East Asia, an episode of intense anxiety about the possibility that the penis or
nipples will recede into the body, possibly leading to death.

6. Hikikomori (withdrawal)- refers to a syndrome observed in Japan, Taiwan, and South Korea in which an
individual, most often an adolescent boy or young adult man, shuts himself into a room (e.g. bedroom) for a
period of 6 months or more and does not socialize with anyone outside the room.

7. Taijin Kyofusho- is a Japanese culture-specific syndrome. This is the fear of interpersonal relations. Those
who have this are likely to be extremely embarrassed about themselves or fearful of displeasing others when it
comes to the functions of their bodies or their appearances. Symptoms of this syndrome overlap with that of
social phobia and body dysmorphic disorder.
Causal Factors in Abnormal Psychology

Etiology- study of origins; causal patterns; it explains why a mental disorder begins and what causes it. It
includes psychological, biological, and even social dimensions.

(1) Distal/Predisposing Cause- anything that produces a susceptibility or disposition to a condition without
actually eliciting it. This includes conditions that occurred relatively early in life but may not show its effect
right away.

(2) Proximal/Precipitating Cause- factor that initiates the onset of manifestations of a disease process; trigger
of the disorder.

(3) Reinforcing Cause- a condition that tends to maintain maladaptive behavior that is already occurring.
Illustration: Imagine a plant that starts as a seed. The seed is the distal cause. Water and soil in this case, are
the proximal causes. Water, soil, sunlight are the reinforcing causes.

❖ Risk Factors- these are factors that increase the possibility of an individual to develop a disorder.
❖ Protective Factors- influences that modify a person’s response to an environmental stressor, lessening the
impact of stress. (e.g. resilience of Filipinos)
 TREATMENT AND INTERVENTIONS

(1) Biologically-based Therapies:

a. Electroconvulsive Therapy (ECT)- addresses major depression.

b. Neurosurgery- craniotomy
c. Psychopharmacotherapy- which drugs work to alleviate the disorders. Before, pharmacological treatments
are divided into 4:

(1) Antipsychotics
(2) Antidepressants
(3) Antianxiety/Anxiolytics
(4) Mood-stabilizing drugs

Now, this is less valid in DSM-5 because:

1.Many drugs of one class are used to treat disorders previously assigned to other class.
2.Drugs from all 4 categories are used to treat disorders not previously treatable by drugs (e.g. eating
disorders, impulse-control disorder, panic disorder)
3.Other drugs such as Clonidine (catapres), Propanolol (Inderal), and Verapanil (Isoptin) can effectively treat a
variety of disorders and do not fit easily into the aforementioned classification of drugs.
(2) Psychological Therapies/Psychotherapies

a. Psychodynamic Therapy- aims to facilitate the client to achieve insight; uncovering the contents of
the unconscious using different techniques.

b. Behavior Therapy- change the maladaptive behaviors learned through the principles of learning.

c. Cognitive-Behavioral Therapy- aims to change the distorted thought processes of the patient.

d. Humanistic/Existential Therapies- facilitate clients to realize potentials for self-actualization.

e. Family Therapy
Chapter Summary

• Diagnosis is the label or name given for a syndrome.

• Syndrome is a collection or set of signs and symptoms that characterize or suggest a particular disease.

• Signs are objective observation of the syndrome by a physician or clinician.

• Symptoms are subjective. It is the patient’s observation of the syndrome.

• Reliability is the degree to which a measurement is consistent; producing same results.

• Validity is related to whether a measure measures what it is supposed to measure.

• Standardization is the process by which a certain set of standards or norms is determined for a technique to make
its use consistent across different measurements.

• Cultural Concepts of Distress, formerly called Culture Bound Syndromes, are ways that cultural groups experience,
understand, and communicate suffering, behavioral problems, or troubling thoughts and emotions (APA, 2013).

• Cultural Syndromes- are clusters of symptoms and attributions that tend to co-occur among individuals in specific
cultural groups, communities, or contexts and that are recognized locally as coherent patterns of experience.
• Cultural Idioms of Distress- are ways of expressing distress that may not involve specific symptoms or
syndromes, but that provide collective, shared ways of experiencing and talking about personal or social
concerns.

• Cultural Explanations or Perceived Causes are labels, attributions, or features of an explanatory model that
indicate culturally recognized meaning or etiology for symptoms, illness, or distress.

• Distal/Predisposing Cause- anything that produces a susceptibility or disposition to a condition without actually
eliciting it. This includes conditions that occurred relatively early in life but may not show its effect right away.

• Proximal/Precipitating Cause- factor that initiates the onset of manifestations of a disease process; trigger of the
disorder.

• Reinforcing Cause is a condition that tends to maintain maladaptive behavior that is already occurring

• Risk Factors are factors that increase the possibility of an individual to develop a disorder.

• Protective Factors are influences that modify a person’s response to an environmental stressor, lessening the
impact of stress.