Chapter 3 Flashcards

Question

Reliability - Classification issues

Answer 1

A system of classification should describe specific subgroups of symptoms that are clearly evident and can be readily identified by experienced clinicians. If two clinicians interview the patient at separate times on the same day (and assuming the patient’s condition does not change during the day), the two clinicians should see, and perhaps measure, the same set of behaviours and emotions. The psychological disorder can thus be identified reliably (Chmielewski et al., 2015; Kraemer, 2014). Obviously, if the disorder is not readily apparent to both clinicians, the resulting diagnoses might represent bias. One of the most unreliable categories in current classification is the area of personality disorders—chronic, trait-like sets of inappropriate behaviours and emotional reactions that characterize a person’s way of interacting with the world. Although great progress has been made, particularly with certain personality disorders, determining the presence or absence of this type of disorder during one interview is still very difficult (Krueger et al., 2015). In a classic study, Morey and Ochoa (1989) asked 291 mental health professionals to describe an individual with a personality disorder they had recently seen, along with their diagnoses. They also collected from these clinicians detailed information on the actual signs and symptoms present in these patients. In this way, they were able to determine whether the actual diagnosis made by the clinicians matched the objective criteria for the diagnosis as determined by the symptoms. In other words, was the clinician’s diagnosis accurate, based on the presence of symptoms that actually define the diagnosis? Morey and Ochoa (1989) found substantial bias in making diagnoses. For example, clinicians who were either less experienced or were female diagnosed borderline personality disorder more frequently than the criteria indicated. More experienced clinicians and male clinicians diagnosed the condition less frequently than the criteria indicated. Patients who were white, female, or poor were diagnosed with borderline personality disorder more often than the criteria indicated. Although bias among clinicians is always a potential problem, the more reliable the nosology, or system of classification, the less likely it is to creep in during diagnosis.

Answer 2

In addition to being reliable, a system of nosology must be valid. Earlier we described validity as whether something measures what it is designed to measure. A valid diagnosis tells the clinician what is likely to happen with the prototypical patient; it may predict the course of the disorder and the likely effect of one treatment or another. This type of validity is often called predictive validity and sometimes criterion validity, when the outcome is the criterion by which we judge the usefulness of the category. Content validity simply means that if you create criteria for a diagnosis of, say, social phobia, it should reflect the way most experts in the field think of social phobia, as opposed to, say, depression. In other words, you need to get the label right.

Answer 3

Observations of depressed, phobic, or psychotic features stretch back to the earliest recorded observations of human behaviour. Many of these observations were so detailed and complete that we could make a diagnosis today of the individuals they described. Nevertheless, only recently have we attempted the very difficult task of creating a formal nosology that would be useful for scientists and clinicians around the world. As late as 1959, at least nine different systems of varying usefulness were used for classifying psychological disorders worldwide, but only three of the nine systems listed “phobic disorder” as a separate category (Marks, 1969). One reason for this confusion is that creating a useful nosology is easier said than done. Early efforts to classify psychological disorders arose out of the biological tradition, particularly the work of Emil Kraepelin. Kraepelin first identified what we now know as the disorder of schizophrenia. His term for the disorder at the time was dementia praecox. Dementia praecox refers to deterioration of the brain that sometimes occurs with advancing age (dementia) and develops earlier than it is supposed to, or prematurely (praecox). This label (later changed to schizophrenia) reflected Kraepelin’s belief that brain pathology is the cause of this particular disorder. Kraepelin’s landmark 1913 book, Textbook of Psychiatry, described not only dementia praecox but also bipolar disorder, then called manic depressive psychosis. Kraepelin also described a variety of organic brain syndromes. Other well-known figures in their time, such as French psychiatrist Philippe Pinel, characterized psychological disorders, including depression (melancholia), as separate entities; but Kraepelin’s theorizing that psychological disorders are basically biological disturbances had the greatest impact on the development of our nosology and led to an early emphasis on classical categorical strategies. It was not until 1948 that the World Health Organization (WHO) added a section classifying mental disorders to the sixth edition of the ICD. This early system did not have much influence, however. Nor did the first Diagnostic and Statistical Manual (DSM-I) published in 1952 by the American Psychiatric Association. Only in the late 1960s did systems of nosology begin to have some real influence on mental health professionals. In 1968, the American Psychiatric Association published DSM-II, the second edition of its manual, in 1969, WHO published the eighth edition of the ICD, which was all but identical to DSM-II, since leaders in mental health began to realize the importance of at least trying to develop a uniform system of classification. Nevertheless, these systems lacked precision, often relying heavily on unproven theories of etiology not widely accepted by all mental health professionals. To make matters worse, the systems had very little reliability. Two mental health practitioners looking at the same patient often came to very different conclusions based on the nosology at that time. Even as late as the 1970s, many countries, such as France and Russia, had their own systems of nosology. In these countries, the same disorders would be labelled and interpreted very differently.

Answer 4

The year 1980 brought a landmark in the history of nosology: DSM-III, the third edition of the American Psychiatric Association’s manual. Under the leadership of Robert Spitzer, the DSM-III departed radically from its predecessors. Two changes stood out First, the DSM-III attempted to take an atheoretical approach to diagnosis, relying on precise descriptions of the disorders as they presented to clinicians rather than on psychoanalytic or biological theories of etiology. With this focus, the DSM-III became a tool for clinicians with a variety of points of view. For example, rather than classifying phobia under the broad category “neurosis,” defined by intrapsychic conflicts and defence mechanisms, it was assigned its own category within a new broader group, “anxiety disorders.” The second major change in the DSM-III was that the specificity and detail with which the criteria for identifying a disorder were listed made it possible to study their reliability and validity. Although not all categories in the DSM-III (and its 1987 revision, DSM-III-R) achieved perfect or even good reliability and validity, this system was a vast improvement over what was available before. Despite numerous shortcomings, such as low reliability in identifying some disorders and arbitrary decisions on criteria for many disorders, the DSM-III and DSM-III-R had a substantial impact. Maser, Kaelber, and Weise (1991) surveyed the international usage of various diagnostic systems at that time and found that the DSM-III had become popular for a number of reasons. Primary among them were its precise descriptive format and its neutrality with regard to presuming a cause for diagnosis. The multiaxial format, which emphasizes a broad consideration of the whole individual rather than a narrow focus on the disorder alone, was also thought to be useful. Therefore, more clinicians around the world used the DSM-III-R at the beginning of the 1990s than the ICD system, which was designed to be applicable internationally

Answer 5

The ICD-10 (WHO, 1992) was published in 1992. To make the ICD-10 and the DSM as compatible as possible, work proceeded more or less as a collaboration between the developers of the ICD-10 and the fourth edition of the DSM (DSM-IV) published in 1994. Although the final versions of both classifications share important similarities by virtue of the categories included and their definitions, there were important distinctions (First, 2009). The DSM-IV task force decided to rely as little as possible on a consensus of experts. Any changes in the diagnostic system were to be based on sound scientific data. The revisers attempted to review the voluminous literature in all areas pertaining to the diagnostic system (Widiger et al., 1996, 1998) and to identify large sets of data that might have been collected for other reasons but that, with reanalysis, would be useful to the DSM-IV. Finally, 12 independent studies or field trials examined the reliability and validity of alternative sets of definitions or criteria and, in some cases, the possibility of creating a new diagnosis. Perhaps the most substantial change in the DSM-IV was that the distinction between organically based disorders and psychologically based disorders that was present in previous editions was eliminated. As you saw in Chapter 2, we now know that even disorders associated with known brain pathology are substantially affected by psychological and social influences. Similarly, disorders previously described as psychological in origin certainly have biological components and, most likely, identifiable brain circuits. In 2000, a committee updated the text that describes the research literature accompanying the DSM-IV diagnostic category and made minor changes to some of the criteria themselves to improve consistency. This text revision (DSM-IV-TR) helped clarify many issues related to the diagnosis of psychological disorders.

Answer 6

he DSM-5 was published in spring 2013. This massive undertaking was also carried out with considerable collaboration with international leaders working simultaneously on ICD-11 such that each workgroup responsible for a set of disorders (e.g., anxiety disorders) had an international expert deeply involved in the work of the committee. Although working group members for the ICD-11 were asked to consider the poten- tial global applicability of the DSM-5, as was the case for ICD-10, the ICD-11 will contain conceptual differences (e.g., the placement of some disorders) and structural differences (e.g., the ICD avoids the use of arbitrary symptom counts to establish a diagno- sis) from DSM-5 (First, Reed, et al., 2015). One motivation for these changes was to make the ICD-11 as clinically useful as possible for clinicians working in vastly varied settings and circumstances, all over the world. The differences, in part, reflect the public health mandate of the ICD as a WHO document, although care was taken in the harmonization process with the DSM-5 to avoid inadvertent differences (First, 2009). University of Ottawa professors Cary Kogan and Sabrina Paterniti have provided a useful analysis of the strengths and weaknesses of DSM-5 and the ICD-11 in the Canadian context The general consensus is that the DSM-5 is largely unchanged from the DSM-IV, although some new disorders are introduced and other disorders have been reclassified. There have also been some organizational and structural changes in the diagnostic manual itself. For example, the manual is divided into three main sections. The first section introduces the manual and describes how best to use it. The second section presents the disorders themselves, and the third section includes descriptions of disorders or conditions that need further research before they can qualify as official diagnoses. The use of dimensional axes for rating severity, intensity, frequency, or duration of specific disorders in a relatively uniform manner across all disorders is also a feature of DSM-5. For example, for PTSD, LeBeau et al. (2014) developed the National Stressful Events Survey PTSD Short Scale (NSESSS–PTSD), which is a nine-item self-report scale based on data from a national study of U.S. adults (Kilpatrick et al., 2010). This scale was reviewed and approved by the DSM-5 workgroup to assess the severity of PTSD symptoms over the past seven days. In addition to dimensional assessments of severity or intensity for individual disorders, the DSM-5 introduces cross-cutting dimensional symptom measures. These assessments are not specific to any particular disorder but rather evaluate, in a global sense, important symptoms that are often present across disorders, in almost all patients. Examples include anxiety, depression, and problems with sleep (Narrow et al., 2014). The idea is to monitor the symptoms, if present, across the course of treatment for the presenting disorder. Thus one might diagnose bipolar disorder and provide a dimensional rating of the degree of anxiety also present because a greater degree of anxiety seems to predict a poorer response to treatment and thus may require additional treatment (Howland et al., 2009; Deckersbach et al., 2014). The suggested questions in the DSM-5 are: “During the past two weeks how much (or how often) have you been bothered by (1) feeling nervous, anxious, frightened, worried, or on edge? (2) feeling panic or being frightened? or (3) avoiding situations that make you anxious?” (American Psychi- atric Association, 2013, p. 738). The DSM-5 uses a 0 to 4 scale where 0 = no anxiety and 4 = very severe anxiety. Notice that this revision does not represent a change to the categories of disorders themselves; rather, these dimensions are added on to the categorical diagnoses to provide clinicians with additional information for assessment, treatment planning, and treatment monitoring. Specific changes to diagnostic categories and new diagnoses will be described in subsequent chapters.

Answer 7

In Frank’s case, initial observations indicate an obsessive-compulsive disorder diagnosis. He might also have long-standing person- ality traits that lead him to systematically avoid social contact. If so, there might also be a diagnosis of schizoid personality disor- der. Job and marital difficulties might be indicated where clini- cians note psychosocial or environmental problems that are not part of the disorder but might make it worse or affect treatment planning. Similarly, overall severity and impairment would be rated in a dimensional fashion periodically, as just described for PTSD, to monitor response to treatment by using a DSM-5 scale devised for that purpose (LeBeau et al., 2013). It is important to emphasize that impairment is a crucial deter- mination in making any diagnosis. For example, if someone, such as Frank, has all the symptoms of obsessive-compulsive disorder but finds them only mildly annoying because the intrusive thoughts are not severe and don’t occur that often, that person would not meet the criteria for a psychological disorder. It is essential that the various behaviours and cognitions composing the diagnosis interfere with functioning in some substantial manner. Thus, the criteria for disorders include the provision that the disorder must cause clinically significant distress or impairment in social, occupational, or other important areas of function- ing. Individuals who have all the symptoms as noted earlier but do not cross this threshold of impairment could not be diagnosed with a disorder. As noted, one change in the DSM-5 is to make this judgment of severity and impairment more systematic by using a dimensional scale. In one of our own clinics, we have been doing something similar to this for many years (Brown & Barlow, 2014). For instance, we have used a scale of 0 to 8, where 0 is no impairment and 8 is severely disturbing or disabling (usually housebound and barely functional). The disorder must be rated at least a 4 in severity (definitely disturbing or disabling) to meet the criteria for a psychological disorder. Many times, disorders such as obsessive-compulsive disorder would be rated a 2 or 3, meaning that all of the symptoms are there but in too mild a form to impair functioning; in this case, the disorder would be termed subthreshold. Using Frank as an example again, the sever- ity of his obsessive-compulsive disorder would be rated 5.

Answer 8

By emphasizing levels of stress in the environment, the DSM-III and DSM-IV facilitated a more complete picture of the individual. Furthermore, the DSM-IV corrected a previous omission by including a plan for integrating important social and cultural influences on diagnosis, a feature that remains in the DSM-5. “Culture” refers to the values, knowledge, and practices that individuals derive from membership in different ethnic groups, reli- gious groups, or other social groups, as well as how membership in these groups may affect the individual’s perspective on their experience with psychological disorders. The plan, referred to as “cultural formulation,” allows the disorder to be described from the perspective of the patient’s personal experience and in terms of the primary social and cultural group, such as Chinese or Indigenous Peoples. Answering suggested culture-related ques- tions from the DSM-5 Cultural Formulation Interview (American Psychiatric Association, 2013) will help accomplish these goals. The following are suggestions for accomplishing these goals (Mezzich et al., 1993, 1999): 1. What is the primary cultural reference group of the patient? For recent immigrants to the country and other ethnic minorities, how involved are they with their new culture versus their old culture? Have they mastered the language of their new country (e.g., English or French in Canada) or is language a continuing problem? 2. Does the patient use terms and descriptions from his or her old country or culture to describe the disorder? For example, as we will see in Chapter 5, kayak-angst in the Inuit culture is a type of anxiety disorder close to panic disorder with agoraphobia. Does the patient accept Western models of disease or disorder in which treatment is available in health-care systems, or does the patient also have an alternative health- care system in another culture (e.g., traditional herbal doctors in Chinese subcultures)? 3. What does it mean to have a disability? What kinds of disabilities are acceptable in a given culture, and which are not? For example, is it acceptable to be physically ill but not anxious or depressed? What are the typical family, social, and religious supports in the culture? Are they available to the patient? Does the clinician understand the first language of the patient and the cultural significance of the disorder? These cultural considerations must not be overlooked in making diagnoses and planning treatment, and they are assumed throughout this book. But, as yet, there is no research supporting the use of these cultural formulation guidelines (Aggarwal et al., 2013). The consensus is that we have a lot more work to do in this area to make our nosology truly culturally sensitive.

Answer 9

Because the collaboration among groups creating the ICD-11 and DSM-5 was largely successful, it is clear that the DSM-5 and the closely related ICD-11’s section on mental disorders are the most advanced, scientifically based systems of nosology ever developed. Nevertheless, any nosological system should be considered a work in progress and the DSM-5 has attempted to put operations in place allowing for interim revisions to categories as new information becomes available; for instance, updates are published e online by the American Psychiatric Association For the time being, we still have fuzzy categories that blur at the edges, making diagnostic decisions difficult at times. As a consequence, individuals are often diagnosed with more than one psychological disorder at the same time, which is called comorbidity. How can we conclude anything definite about the course of a disorder, the response to treatment, or the likelihood of associated problems if we are dealing with combinations of disorders (Allen et al., 2010; Brown & Barlow, 2009; Krueger et al., 2014)? Is there a way to identify essential features of comorbid disorders and, perhaps, rate them dimensionally (Brown & Barlow, 2009; Rosellini et al., 2015)? Resolution of these tough problems simply awaits the long, slow process of science. Criticisms of the DSM-5 and the forthcoming ICD-11 centre on two other aspects. First, the systems strongly emphasize reliability, sometimes at the expense of validity. This is understandable, because reliability is so difficult to achieve unless you are willing to sacrifice validity. If the sole criterion for establishing depression were to hear the patient say at some point during an interview, “I feel depressed,” the clinician could theoretically achieve perfect reliability. But this achievement would be at the expense of validity because many people with differing psychological disorders, or none, occasionally say they are depressed. Thus, clinicians could agree that the statement occurred, but it would be of little use (Meehl, 1989). Second, as Carson (1996) pointed out, meth- ods of constructing a nosology of mental disorders have a way of perpetuating definitions handed down to us from past decades, even if they might be fundamentally flawed (Lillienfield, 2014). Some (e.g., Markon, 2013) think that it might be better to start fresh once in a while and create a new system of disorders, or several new systems, based on emerging scientific knowledge and see which one turns out to be best rather than to simply fine-tune old definitions. But this is unlikely to happen because of the enormous effort and expense involved and the necessity of discarding the accumulated wisdom of previous versions. In addition to the daunting complexity of categorizing psychological disorders, systems are subject to misuse, some of which can be dangerous and harmful. Diagnostic categories are just a convenient format for organizing observations that help professionals communicate, study, and plan. But if we reify a category, we literally make it a “thing,” assuming it has a meaning that, in reality, may not exist. Categories may change occasionally with new knowledge, so none can be written in stone. If a case falls on the fuzzy borders between diagnostic categories, we should not expend all our energy attempting to force it into one category or another. It is a mistaken assumption that everything has to fit neatly somewhere.

Answer 10

A related problem that occurs any time we categorize people is labelling. You may remember Kermit the Frog from Sesame Street sharing with us that “It’s not easy being green.” Something in human nature causes us to use a label, even one as superficial as skin colour, to characterize the totality of an individual (“He’s green . . . he’s different from me”). We see the same phenomenon among psychological disorders (“He’s a schizo”). Furthermore, if the disorder is associated with an impairment in cognitive or behavioural functioning, the label itself has negative connotations and contributes to stigma, which is a combination of stereotypic negative beliefs, prejudices, and attitudes resulting in reduced life opportunities for the devalued group in question, such as individuals with mental disorders There have been many attempts over the years to categorize intellectual disability. Most of the categories were based on the severity of the impairment or highest level of developmental ability that the individual could reach. But we have had to change the labels for these categories of cognitive impairment periodically as the stigma associated with them builds up. One early categorization described levels of severity as moron (least severe), imbecile, and idiot (most severe). When these terms were introduced they were rather neutral, simply describing the severity of a person’s cognitive and developmental impairment. But as they began to be used in common language, they picked up negative connotations and were used as insults. As these terms gradually became pejorative, it was necessary to eliminate them as categories and come up with a new set of classifying labels that were less derogatory. One recent development is to categorize intellectual disability functionally in terms of the levels of support needed by these individuals. In other words, a person’s degree of intellectual disability is determined by how much assistance he or she requires (e.g., intermittent, limited, extensive, or pervasive) rather than by his or her IQ score (Lubinski, 2004; Luckasson et al., 1992). In the DSM-5 the term “mental retardation” has been dropped in favour of the more accurate term “intellectual disabil- ity,” which is further described as mild, moderate, severe, or profound (American Psychiatric Association, 2013). Many efforts have been made in Canada to reduce the stigma associated with mental disorders. The Mental Health Commission of Canada has created anti-stigma programs, such as HEAD-STRONG for schools, and initiatives, such as Mental Health First Aid for the workplace so that coworkers can become more informed about mental illness and better help people struggling

Answer 11

During the extensive deliberations that led to the publication of both the DSM-IV and the DSM-5, several potentially new diagnostic categories were considered. Because one of us was a member of the DSM-IV task force, the final decision-making body overseeing the creation of the DSM, and an adviser to DSM-5, we can offer brief examples to illustrate how diagnostic categories are created. In one case, a potential new diagnosis was not included in the DSM-5; in a second case, a new diagnosis was indeed created. We now briefly describe each case. - Mixed Anxiety-Depression - Premenstrual Dysphoric Disorder

Answer 12

Family physicians’ offices, clinics, hospitals, and so on, are called primary care settings because they are where a person goes first with a problem. Health-care professionals examining these individuals report that their symptoms of anxiety and depression are classic but not frequent or severe enough to be an existing anxiety or mood disorder The DSM-IV task force was concerned about issues like this one for several reasons. First, because many individuals present with some minor symptoms of a given disorder, it is important to set thresholds high enough that only people who clearly experience some impairment qualify for the category. (Thresholds are the minimum number of criteria required to meet the definition of a disorder.) The primary reason for this concern is that substantial legal and policy implications are contingent on a diagnosis. That is, someone who presents with a psychological disorder that clearly qualifies for a diagnosis becomes part of the loosely orga- nized medico-legal system and is eligible to ask the government or private insurance companies for financial reimbursement or disability payments. In Canada, the services provided by a psychologist are covered by provincial health insurance only if the psychologist is employed by a publicly funded institution like a hospital, community health clinic, school, social agency, or correctional facility. In contrast, services provided by a psychologist in private practice are not covered by provincial or territorial health-care plans. These costs are either paid for by the patient or covered partially or in full by health benefits through private insurance plans offered by employers. The services of psychiatrists are covered through provincial health insurance plans regardless of where the psychiatrist is employed (Canadian Psychological Association, 2004). Disability payments are covered by the Canada Pension Plan based on contributions from workers and employers in Canada. The primary role of this plan is to replace a portion of income for contributors who cannot work because of a severe and prolonged disability, such as a severe mental health disorder Clearly, if the diagnostic system includes people who have only minor symptoms, who are not particularly impaired and just feel down periodically, or who don’t like their job and want disability (an all-too-common request in mental health clinics), the health-care system would be even more strained and have fewer resources to treat the serious impairments. But if people are experiencing considerable problems and impairment in function- ing, they should be covered in any health-care system. For these reasons, minor complaints of dysphoric mood, characterized by vague complaints of anxiety and depression, were not considered sufficiently severe to constitute a formal diagnosis. In 1989, Klerman and Weissman, reporting on a large study by Wells et al. (1989), found that patients who claimed to be anxious and mildly depressed were impaired in a number of areas when compared with normal controls and with patients with chronic medical conditions. Substantial impairment was present in the areas of physical and social functioning, not only causing patients to miss work but also interfering with their functioning in the home; it was worse than the impairment of many patients with chronic medical conditions. The evidence also suggested that these individuals were already imposing an enormous burden on the health-care system by appearing in large numbers at community health clinics and the offices of family doctors. Therefore, we concluded that it might be very valuable to identify these people and find out more about the etiology, course, and maintenance of the problem. The authors of the ICD-10, recognizing this phenomenon is prevalent throughout the world, had created a category of mixed anxiety-depression, but they had not defined it or created any criteria that would allow further examination of the potential disorder. Therefore, to explore the possibility of creating a new diagnostic category (Zinbarg & Barlow, 1996; Zinbarg et al., 1994, 1998), a study was undertaken that had three specific goals. First, if mental health professionals carefully administered semistructured interviews (the Anxiety Disorders Interview Schedule), would they find patients who fit the new category? Or would careful examination find the criteria for already existing disorders that had been overlooked by health professionals not well trained in identifying psychological disor- ders? Second, if mixed anxiety-depression did exist, was it really more prevalent in medical primary care settings than in outpatient mental health settings? Third, what set of criteria (e.g., types and number of symptoms) would best identify the disorder? The study to answer these questions was conducted simultane- ously in seven sites around the world (Zinbarg et al., 1994, 1998). Results indicated that people presenting with several symptoms of anxiety and depression, who did not meet the criteria for an existing anxiety or mood disorder (because they did not have the right mix or severity of anxious or depressed symptoms), were common in primary care settings. Furthermore, they were substan- tially impaired in their occupational and social functioning and experienced a great deal of distress. Additional analysis revealed that such people could be distinguished from people with existing anxiety or mood disorders on the basis of their symptoms with the very careful and detailed assessment procedures used. Because these people appeared both anxious and depressed, the potential new category possessed content validity. This study also established some of the criteria important in determining construct validity for the new category of mixed anxiety-depression. Because the category is so new, however, we do not have information on additional criteria important in estab- lishing construct validity, such as course, response to treatment, and the extent to which the disorder aggregates in families, and we cannot yet verify the reliability of the diagnosis or anything about predictive validity. Therefore, the decision of the DSM-IV task force was to place this mixed anxiety-depression diagnosis in the appendix, which is reserved for new diagnoses under study. After the publication of the DSM-IV, several studies re-examined this issue to see if mixed anxiety-depression should be included in the DSM-5 (e.g., Weisberg et al., 2005). The general conclusion was that although people do present with these symptoms, it is relatively rare in the absence of a current or previous anxiety or mood disorder, the mixed anxiety-depressive symptoms do not last long, and it was very difficult to identify the condition in a reliable fashion. The findings eliminated further consideration of mixed anxiety-depression as a new and separate diagnosis; in fact, is was not even placed in Section 3 where disorders needing further study are found in DSM-5, and it is unlikely it will be considered in future DSM editions.

Answer 13

Premenstrual dysphoric disorder (PMDD) evokes a very different issue that must be considered in the creation of any diagnostic category: bias and stigmatization. Evaluation of PMDD as a diag- nostic category actually began well before the publication of DSM-III-R in 1987. Some clinicians had claimed to have identi- fied a small group of women who presented with severe and sometimes incapacitating emotional reactions associated with the late luteal phase of their menstrual cycle (Rivera-Tovar et al., 1992). Subsequently, proposals were made to consider inclusion of this possible disorder in the DSM-III-R. In view of the difficul- ties and impairment associated with this condition, the propo- nents argued, women deserved the attention, care, and financial support that inclusion in a diagnostic category would provide. In addition, as with mixed anxiety-depression, proponents argued that the creation of this category would promote a substantial increase in research into the nature and treatment of the problem. Di Guilio and Reissing (2006) of the University of Ottawa, for example, argue that the accumulated research suggests that PMDD represents a distinct diagnostic entity that is separable from both normal premenstrual symptoms and major depression. They argue that recognition of this problem through formal diag- nostic criteria would serve the important minority of women who suffer from this cyclical mood “disorder.” Nevertheless, arguments against the category were marshalled along several fronts. First, opponents noted that relatively little scientific information existed in either the clinical or research literature on this topic. The available information was insufficient to warrant the creation of a new diagnostic category. More impor- tant were substantial objections that what could be a normal endocrinological stage experienced by all or most women would be stigmatized as a psychiatric disorder. Some pointed to research showing that women who complain of premenstrual emotional symptoms are significantly more likely than other women to be in distressing life situations (e.g., being battered); thus, to label them as having a mental disorder may mask the real, external (societal) sources of their difficulties (see the review by Offman & Klein- platz, 2004). In addition, the seeming similarities with the once widely accepted category of hysteria described in Chapter 1 were also noted. Questions were raised about whether the disorder would best be described as endocrinological or gynecological rather than psychological. Because premenstrual dysphoric disor- der could occur only in women, should we include a comparable disorder associated with, for example, aggressiveness related to excessive male hormones? The DSM-III-R task force decided to place this disorder in an appendix in the hope of promoting further study. The task force also wanted to clearly differentiate this syndrome from premen- strual syndrome (PMS), which has less severe and specific premenstrual symptoms. One way of accomplishing this was by naming the condition late luteal phase dysphoric disorder (LLPDD). After the publication of the DSM-III-R, LLPDD attracted a great deal of research attention. By 1991, Judith Gold, a psychia- trist from Halifax, Nova Scotia, who chaired the DSM-IV work group on this issue, estimated that one research article per month on LLPDD was published (Gold et al., 1996). A variety of scien- tific findings began to accrue that supported the inclusion of this disorder in the DSM-IV. For example, although the rather vague and less severe symptoms of PMS occur in 20 percent to 40 percent of women (Severino & Moline, 1989), only a very small proportion of them—about 5 percent—experience the more severe and incapacitating symptoms associated with LLPDD (Rivera-Tovar & Frank, 1990). In addition, abnormali- ties in several biological systems appear to be associated with clinically significant premenstrual dysphoria (reviewed in Gold et al., 1996), and several different types of treatment showed promise of being effective with LLPDD (e.g., Stone et al., 1991). Hurt and colleagues, in a reanalysis of data from 670 women, recommended a set of criteria for this disorder that were not very different from those proposed in the DSM-III-R (Hurt et al., 1992). Nevertheless, arguments continued against including this label in the diagnostic system. Most opponents cite the issue of stigma- tization, warning that recognition might confirm the cultural belief that menstruation and resulting disability make women unfit for positions of responsibility. (There have been several cases where accusations of the less severe condition of PMS have been used against a mother in an attempt to win child custody for the father; see Gold et al., 1996.) Those arguing against the disor- der also point out that some of the symptoms outlined in the criteria for LLPDD involve anger, which would not be viewed as inappropriate in a male. Only in a female does society presume that anger signifies something is wrong. Interestingly, many women who have been given this label say they are quite comfortable with it. Some women presenting with other psychological disorders, such as depression, refuse to accept the suggestion that they have a psychiatric problem, insisting it is really premenstrual syndrome (Rapkin et al., 1989). Early in 1994, the DSM-IV task force decided to retain the disorder in the appendix as needing further study. The commit- tee wanted to see more epidemiological data using the new criteria and to examine more carefully the data on the relation of this problem to existing mood disorders, among other problems. Several additional research findings indicated that the name late luteal phase dysphoric disorder was not entirely accurate, because the symptoms may not be exclusively related to the endo- crine state of the late luteal phase. Therefore, the name has been changed to premenstrual dysphoric disorder (PMDD). Since 1994, research has continued, and even accelerated, on the nature and treatment of PMDD, with thousands of papers published on this general topic (Bloch et al., 2014; Epperson et al., 2012; Hartlage et al., 2012; O’Brien et al., 2011; Pearlstein, 2010; Zachar & Kendler, 2014). Epidemiological studies from around the world supported the existence of disabling premen- strual symptoms in 2 to 5 percent of women, with another 14 to 18 percent experiencing moderate symptoms (Cunningham et al., 2009; Epperson et al., 2012; Gold, 1997a, 1997b; Ko et al., 1996; Pearlstein & Steiner, 2008). The American College of Obstetri- cians and Gynecologists (2002) has published systematic clinical practice guidelines recommending specific treatments, and new information on effective treatment is published frequently (Epperson et al., 2012; Freeman et al., 2009; Jang et al., 2014; Yonkers et al., 2014). One of the difficulties encountered has been distinguishing PMDD from premenstrual exacerbations of other disorders, such as binge eating disorder or mood disorders (Pearlstein et al., 2005). Hartlage et al. (2012) proposed a method that carefully considers the nature and timing of the symptoms to make a valid distinction between PMDD and premenstrual exac- erbations of other disorders. For example, the symptoms of PMDD must be absent or present only mildly postmenstrually. To distinguish it from a mood disorder, at least some symptoms must be different from those associated with a mood disorder, such as certain physical symptoms or anxiety. The accumulating evidence thus far seems to suggest that PMDD is best considered a disorder of mood rather than, for example, an endocrine disor- der and that it should continue to be considered a psychological disorder (Cunningham et al., 2009; Gold, 1999). Support for PMDD is now sufficient that it is now included as a distinct psychological disorder in the DSM-5 in the chapter on mood disorders.

Answer 14

The process of changing the criteria for existing diagnoses and creating new ones will continue as science advances. New find- ings on brain circuits, cognitive processes, and cultural factors that affect our behaviour could date diagnostic criteria relatively quickly. although some new disorders have been added, and others relocated from one section to another, overall the DSM-5 has not changed substantially from the DSM-IV. Nevertheless, it has been clear to most professionals involved in this process that an exclusive reliance on discrete diagnostic categories has not achieved its objective in achieving a satisfactory system of nosology In addition to problems noted earlier with comorbidity and the fuzzy boundary between diagnostic categories, little evidence has emerged validating these categories, such as discovering specific underlying causes associated with each (Regier et al., 2009). In fact, not one biological marker, such as a laboratory test, that would clearly distinguish one disorder from another has been discovered (Frances, 2009; Widiger & Cregor, 2013; Widiger & Samuel, 2005). One exception might be narcolepsy, which seems to be associated with specific cerebrospinal biomarkers (e.g., Heier et al., 2014). It is also clear that the current categories lack treatment specificity. That is, certain treatments, such as cogni- tive-behavioural therapies or specific antidepressant drugs, are effective for a large number of diagnostic categories that are not supposed to be all that similar. Therefore, although some progress has been made, many are beginning to assume that the limitations of the current diagnostic system are substantial enough that continued research on these diagnostic categories may never be successful in uncovering their underlying causes or helping us develop new treatments. It may be time for a new approach. A suggestion strongly supported by the last two directors of the U.S. National Institute of Mental Health (Hyman, 2010; Insel et al., 2010; Insel, 2014). Most people agree that this approach will incorporate a dimen- sional strategy to a much greater extent than in DSM-5 (Krueger & Markon, 2014; Widiger & Cregor, 2013). The term “spectrum” is another way to describe groups of disorders that share certain basic biological or psychological qualities or dimensions. For example, in Chapter 15 you will read about one of the notable advances in the DSM-5 where the term “Asperger’s syndrome” (a mild form of autism) was integrated with autistic disorder into a new category of “autism spectrum disorder.” But it is also clear at this point that research is not sufficiently advanced to attempt a wholesale switch to a dimensional or spectrum approach, so the categories in the DSM-5 for the most part look very much like the categories in the DSM-IV with some updated language and increased precision and clarity. But sparked by research and conceptual advances during the process of creating the DSM-5, more conceptually substantial and consistent dimensional approaches are in development and may be ready for the 6th edition of the DSM in 10 to 20 years. For example, most investigators have concluded that personal- ity disorders are not qualitatively distinct from the personalities of normal-functioning individuals in community samples (Krueger et al., 2014; Trull et al., 2013). Instead, personality disorders simply represent maladaptive, and perhaps extreme, variants of common personality traits (Widiger & Edmundson, 2011; Widiger et al., 2009). Even the genetic structure of personality is not consistent with discrete categorical personality disorders. That is, personality dispositions more broadly defined, such as being shy and inhibited or outgoing, have a stronger genetic influence (higher genetic loading) than personality disorders as currently defined (First et al., 2002; Livesley & Jang, 2008; Livesley et al., 1998; Rutter et al., 2006; Widiger et al., 2009). For the anxiety and mood disorders, Brown and Barlow (2009) have proposed a new dimensional system of classification based on previous research (Brown et al., 1998) demonstrating that anxiety and depression have more in common than previously thought and may best be represented as points on a continuum of negative affect or a spectrum of emotional disorders (see Barlow, 2002; Brown & Barlow, 2005, 2009; Rosellini et al., 2015). Even for severe disorders with seemingly stronger genetic influences, such as schizophrenia, it appears that dimensional classification strate- gies or spectrum approaches might prove superior At the same time, exciting new developments from the area of neuroscience relating to brain structure and function will provide enormously important information on the nature of psychological disorders. This information could then be integrated with more psychological, social, and cultural information into a diagnostic system. But even neuroscientists are abandoning the notion that groups of genes or brain circuits will be found that are specifically associated with DSM-5 diagnostic categories, as noted in Chapter 2. Rather, it is now assumed that neurobiological processes will be discovered that are associated with specific cognitive, emotional, and behavioural patterns or traits (e.g., beha- vioural inhibition) that do not necessarily correspond closely with current diagnostic categories.

Chapter 3 Flashcards

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