Developmental Psychopathology and the Diagnostic and Statistical Manual of Mental Disorders

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Developmental Psychopathology and the Diagnostic
and Statistical Manual of Mental Disorders

• Chapter 2
• Theodore P. Beauchaine, Daniel N. Klein, Nora L.
  Erickson, and Alyssa L. Norris

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HISTORICAL CONTEXT

• Early Versions of the DSM
• The DSM-I (APA, 1952)
• An effort by the APA to produce a single
  nomenclature for psychopathology.
• Influenced strongly by Adolph Meyer's
  psychobiology, which viewed psychopathology as a
  reaction to stress.
• Three broad classes of psychopathology included
  organic brain syndromes, functional disorders,
  and mental deficiency.
• 108 specific diagnoses with only one applied to
  children.
• Little basis in empirical research.

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HISTORICAL CONTEXT

• The DSM-II (APA, 1968)
• Major goal was to improve communication among
  mental health professionalsespecially
  psychiatrists.
• Strong psychoanalytic influences.
• Major diagnostic classes of psychopathology were
  expended from 3 to 11.
• A number of childhood and adolescent disorders
  were added.
• The seventh printing of the DSM-II (APA, 1974),
  homosexuality was removed as a mental disorder.

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Reliability, Validity, and Subsequent Versions of
the DSM

• The DSM-III (APA, 1980)
• Designed to be descriptive and largely
  atheoertical, so it would be useful to
  professionals from a variety of disciplines.
• Clinical features and etiology of major forms of
  psychopathology were important influences
  reducing the strong psychoanalytic overtones of
  prior versions of the DSM.
• Diagnosis played a central role as a reliable and
  valid classification system.

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Reliability, Validity, and Subsequent Versions of
the DSM

• Limited evidence of inter-rater reliability of
  psychiatric diagnosis, a major obstacle for
  reliable diagnosis
• Problems with reliability
• Rates of various diagnoses differed dramatically
  between the United States and most European
  countries.
• Studies addressing diagnostic reliability
  indicated very low inter-rater agreement.

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Reliability, Validity, and Subsequent Versions of
the DSM

• Operationalizing Diagnostic Criteria Reducing
  Criterion Variance
• Feighner Criteria (1972) stated that diagnostic
  validity can be established when a clinical
  syndrome is characterized by
• A cluster of covarying symptoms and etiological
  precursors (obtained from clinical description)
• Reliable physiological, biological, and/or
  psychological markers obtained from clinical
  description)
• Readily definable exclusionary criteria
• Predictable course (assessed through follow-up
  studies)
• Increased rates of the same disorder among
  first-degree relatives (assessed through family
  studies).

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Reliability, Validity, and Subsequent Versions of
the DSM

• Structured Interviews Reducing Information
  Variance
• Present State Examination (PSE) A systematic
  assessment of patients' current symptoms. It did
  not collect information on previous history.
• Schedule for the Affective Disorders and
  Schizophrenia (SADS) Allowed clinicians to
  collect systematic and reliable data on both
  current symptoms and history of most major
  psychiatric disorders.

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Reliability, Validity, and Subsequent Versions of
the DSM

• Structured Clinical Interview for DSM-III (SCID)
  Assessed all major disorders in the DSM-III and
  was less time consuming than the PSE and the
  SADS.
• Diagnostic Interview Schedule (DIS) A
  respondent-based measure designed for use by
  nonclinicians leaving no room for interviewer
  judgment in formulating questions and rating
  symptoms.
• Diagnostic Interview Schedule for Children
  (DISC) assesses DSM-IV-TR (APA, 2000)
  psychiatric disorders, designed for use with
  parents of children ages 6 to 17 and with
  children and adolescents ages 9 to 17.

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Reliability, Validity, and Subsequent Versions of
the DSM

• The DSM-III, DSM-III-R, and DSM-IV
• The DSM-III (APA, 1980)
• The first official classification system in
  psychopathology that used specific symptoms,
  including inclusion, exclusion, and duration
  criteria for each diagnosis.
• Multiaxial classification addressed patients
  uniqueness in making a diagnosis.
• Axis I Major psychiatric syndromes
• Axis II Personality disorders
• Axis III Physical conditions that are relevant
  to understanding a persons presenting problem
• Axis IV Psychosocial and environmental stressors
  and problems
• Axis V And overall severity, or global
  assessment of functioning (GAF)

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Reliability, Validity, and Subsequent Versions of
the DSM

• DSM-III-R (APA, 1987)
• Exclusion criteria were eliminated from the
  DSM-III-R, except those used to rule out an
  organic causes of disorder.
• The elimination of exclusion criteria lead to an
  increase in rates of comorbidity, or the
  co-occurrence of two or more disorders.
• DSM-IV (APA, 1994)
• Revisions were more data driven than in previous
  versions, and the process was more systematic and
  better documented.
• DSM-IV-TR (APA, 2000)
• Factual errors were corrected sections of text
  describing each diagnostic category, associated
  features, advances in laboratory and clinical
  research, etc., were revised based on new
  research.

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THE DSM AND DEVELOPMENTAL PSYCHOPATHOLOGY

• Criticisms of the DSM Approach
• Problems with construct validity
• Construct validity refers to the extent to which
  symptoms of a diagnosis mark an objective,
  nonarbitrary entity that relates to mental health
  outcomes.
• Heterogeneity within diagnostic classes
• Equifinality states that diverse etiologies
  often result in what appears to be a single
  disorder. However, since DSM diagnoses are all
  derived syndromally different underlying causes
  of a disorder may never be ascertained.
• Categorical versus dimensional measurement
• Overly categorical diagnosis losses information
  about individual differences in symptoms,
  difficulty ascertaining optimal diagnostic cut
  offs and loss of statistical information.

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THE DSM AND DEVELOPMENTAL PSYCHOPATHOLOGY

• Criticisms of the DSM Approach
• Failure to consider development
• Child and adolescent psychopathology are assessed
  and diagnosed without careful consideration of
  normative developmental trends in behavior, and
  without acknowledgement that of Heterotypic
  continuity, meaning a single behavioral
  traitsincluding those that confer vulnerability
  to psychopathologymay be expressed differently
  at different ages.
• The Axis I-Axis II distinction
• Basis for the distinction between Axis I and Axis
  II often seems arbitrary and some forms of severe
  personality disorders share the same
  etiologiological influences as Axis I disorders.
• The assumption that personality disorders can
  only be diagnosed among adults.
• Failure to consider culture and other contextual
  issues
• Does not account for culturally induced
  individual differences in behavior that might be
  mistaken for psychopathology or cultural,
  socioeconomic, and other contextually driven
  individual differences in the expression of
  psychopathology.

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CHANGES TO THE UPCOMING DSM-5

• Structural changes
• The 20 chapters are sequenced developmentally,
  with disorders usually diagnosed in infancy
  listed first, followed by disorders of childhood,
  adolescence, and adulthood.
• Personality disorder revisions
• The number of personality disorders are reduced
  from 10 to 6 and ratings in three different areas
  are used to diagnose personality pathology.
• Multiaxial system
• Three Axes
• Axis I (psychiatric and medical diagnoses) Will
  included the DSM-IV-TR Axes I (clinical
  disorders) II (developmental and personality
  disorders) and III (general medical conditions).
• Axis II will include Axis IV of the DSM-IV-TR
  (psychosocial and environmental problems).
• Axis III will include Axis V of the DSM-IV-TR
  (global assessment of functioning).

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CONCLUSIONS

• Although the DSM is an important component of
  mental health diagnosis there are still many
  limitations that fail to
• Capture developmental processes underlying
  current and future risk for psychopathology.
• Specify pathophysiological and etiological
  mechanisms of psychopathology.
• Map broad biobehavoioral traits that predispose
  to psychopathology across traditional diagnostic
  boundaries.
• Account fully for contextual influences such as
  ethnicity and culture on the development of
  psychopathology.