This action might not be possible to undo. Are you sure you want to continue?
Informal name given to diagnostic criteria used in
psychiatry First published in 1972 by Feighner et al 14 conditions including primary affective disorders, schizophrenia, anxiety neurosis, ASPD, homosexuality… DSM III was based on these criteria Symptom counting, arbitrary cut-off (e.g. 6 on 10 for depression)
CATEGORICAL SYSTEM Based on medical model Implies that a patient is Different from normal Different from other patients in terms of symptoms. etiology. Pioneered by Feighner et al (1972) . treatment response and outcomes.
Categorical System: MONTHETIC VS POLYTHETIC FORMAT Monothetic format was used in DSM III: 1 or several criteria necessary and sufficient for diagnosis. I. all criteria were given equal weight.e. which made for a more descriptive model . of criteria. Polythetic format was used DSM III R onwards: List of criteria where diagnosis was based on meeting required threshold for certain no.
(ICD) .Categorical System: MONTHETIC VS POLYTHETIC FORMAT But this encouraged heterogeneity in the samples fulfilling the criteria (Eg 93 ways to meet BPD) So most clinicians diagnose based on a prototype they have of a syndrome. This has begun a move back to monothetic approach where essential features are described. which means they did not follow the symptoms systematically or saw the other criteria as ancillary.
Avoidant PD > Schizoid Any other PD > Passive Aggressive PD But clinicians still adhere to this: They give precedence to the disorder that is most prototypically evident.HIERARCHICAL ARRANGEMENTS DSM III had 2 examples (but this was dropped in DSM III R): Schizotypal. .
1% of all PDs) Evidence of diagnostic bias (eg HPD with sex bias) Inclusion criteria: Adequate literature Specified diagnostic criteria Acceptable inter-clinician reliability Evidence that criteria form a syndrome Differenciation from other criteria . 1990) Exclusion criteria: Inadequate literature (eg PAPD) Extremely low coverage (eg Schizoid.INCLUSION VS EXCLUSION (BLASHFIELD ET AL.
MULTIAXIAL VS UNIAXIAL APPROACH Could be used for categorical or dimensional approach Advantages of multiaxial approach: Richer description of patient Research purposes: permits recognition of associations between disorders and other factors Prevents overlooking issues important for patient .
Developmental disorders Axis 3: GMCs Axis 4: Psychosocial stressors Axis 5: GAF .DSM AXES Axis 1: Clinical disorders EXCEPT PD and developmental disorders Axis 2: PD.
developmental disorders B: GMC Axis 2: Disabilities (0-6) Personal care Occupational Familial Social (Z codes) Family/Housing Education/Work Economic/Legal Cultural/Environmental Personal Axis 4: QOL (1-10) .ICD AXES Axis 1: (give codes) A: Clinical disorders Axis 3: Contextual Factors INCLUDING PD.
DSM V will retain operational diagnostic criteria . ICD 11 will retain narrative descriptions.ICD and DSM Aim of ICD – Increased public health utility of system Aim of DSM – Comprehensive Attempts to harmonize ICD and DSM Metastructure Nomenclature Yet.
DIMENSIONAL APPROACH Called threshold psychiatry/dichotomous classification Classifies behaviours not people Involves different aspects of psychological functioning along which people vary with two extremes that people fall between.e. syndrome or subtype) .i. Involves continuums (simple straight lines with no significant discontinuities) whereas categorical approaches are overlaid by spectrums (presence of common denominator. but set of individuals may present with particular pattern or symptoms.
Results in symptom profile similar to MMPI-II Hybrid version of DSM II and later editions. Brevity. that are developed empirically through application of statistical aggregation techniques to large data sets. likert rating of extent to which symptoms taken as a whole match each of several diagnostic prototypes.PROTOTYPE-MATCHING APPROACH Westen et al 2002: Instead of present-absent decisions about criteria/diagnosis. prototypes with easily understood gists .
2011: PM better than “defining features” approach More congruent to human cognitive processes Research: user friendliness.PROTOTYPE-MATCHING APPROACH Maj. clinical utility Drawbacks: Change training =>selective spotting/recall of symptoms “Reading in” May discard prototype for lack of some criteria Still being researched Caution: Studying clinicians instead of patients? .
Subjective Not amenable to verification Not transferable across chronological or cultural barriers Somatic: Based on objective histologic. chemical abnormalities characteristic of various disorders Not yet well-developed in psychiatry .OTHER APPROACHES Descriptive: Based on descriptions of behaviour reported by observations. or symptoms reported by patient themselves.
Arguments for and against the dimensional and categorical approaches .
.ADVANTAGES OF CATEGORIES Greater ease of communication Inter-rater reliability Greater ease for counting purpose Continuity with current clinical practice and clinical decision making (Admission/not? Medication/not?) Orients clinician to primary psychopathology Better fit with reimbursement policies.
ADVANTAGES OF CATEGORIES Anchors the system within psychiatry and medication while placing a desirable premium on public health issues of dysfunction Gives impetus to nosologists to explore and clarify descriptive distinctions while it stimulates search for more distinct etiological factors-or other qualitatively distinct characteristics. would yield increasingly specific and effective treatments . if discovered.as a means for defining these disorders: distinctions that.
DISADVANTAGES OF CATEGORIES Validity and utility Arbitrary cut-offs/time-frames and algorithms that are too cumbersome for clinical practice Comorbidities Mixed/atypical/NOS presentations Subthreshold/subclinical presentations Within-category heterogeneity Dimensional trait measurement in PD => Makes research hard to interpret .
“symptomatic bean counter” . “latent schizophrenia” Stigma of labels Impersonal approach.“masked depression”.DISADVANTAGES OF CATEGORIES Controversial categories (eg homosexuality) Influence of pharmaceutical industry (increase of BPAD diagnosis after advent of Li) Diagnostic fads: Psychiatrists tend to diagnose what they can treat.
ADVANTAGES OF DIMENSIONAL APPROACH Face validity (logical) Research evidence (Haslam.statistical power for detecting discriminations in subsequent analyses Truer to underlying distributions in population Useful in data-analytic procedures . 2003. etc) Explains comorbidity as caused by underlying fundamental dimensions Psychometric advantages.
parsimonious way to code presence or absence of disorders => limited utility in medical. 2005) Plurality of dimensional models + lack of consensus => how to dimensionalize? .DISADVANTAGES OF DIMENSIONAL APPROACH Lacks quick. clinical and insurance settings (First.
QUESTIONS FOR DIMENSIONAL APPROACH Ways to use data to understand whether a psychopathological entity is more dimensional versus more categorical in nature? What dimensions represent the optimal targets for research on psychopathology? Can these dimensions be organized into a few broad. overarching constructs? Are more specific instantiations of these constructs also important? .
QUESTIONS FOR DIMENSIONAL APPROACH Do these dimensions transcend a putative distinction between more normal and more abnormal psychological phenomena? Should a dimensional understanding of psychopathology inform official nosologies such as the DSM? Or must psychopathology research part ways with the DSM to some extent. given that the DSM serves needs that are somewhat separate from those of researchers. such as the need to describe specific categorical diagnoses that can be recorded to facilitate third-party payment for professional services? .
THE 2005 DEBATE IN JOURNAL OF ABN PSY Widiger & Samuel: Specific cut-offs on dimensions. Markon. Patrick. Iacano: Dimensional spectrum of adult externalizing disorders Watson: Quantitative structure underlying mood and anxiety disorders => Superclass with 3 subclasses (distress disorders. bipolar disorders) . disinhibition) Krueger. fear disorders. like MR Clark: PD disagnosis based on 3 major heritable components of temperament (negative affectivity. positive affectivity.
Only five specific PDs are being recommended for retention in DSM-V: borderline. avoidant. . schizotypal.DSM V Hybrid model for PD (based on Schedler and Westen’s prototype-dimensional model) with four main features: A reduction in the number of specified types from 10 to 5 A description of the types in a narrative format that combines typical deficits in self and interpersonal functioning and particular trait configurations A dimensional graded membership rating of the degree to which a patient matches each type A rating of the personality traits most commonly associated each personality type. antisocial/psychopathic (possibly with subtypes). and obsessive-compulsive.
Westen et al.122. pg. American Psychiatric Pub. GB). D (2009). Springer. Volume 11. 114(4): 491–493. Psychiatric diagnosis: pros and cons of prototypes vs. World Psychiatry. Kamphuis JH. pgs 221-251. Rethinking The DSM.wikipedia. On Categorical Diagnosis in DSM V: Cutting Dimensions at Useful Points? Psychological Assessment. Ortigo KM. . Barlow. (2009).org www. 10(2): 81–82. (1988). operational criteria.dsm5. Pages 111. L. www. RF. Pgs 9-24 Cantwell. Chapter 8. Noordhof A. (2002) Simplifying Diagnosis Using A Prototype Matching Approach : Implications for the Next Edition of The DSM. M. D. Baker. Mesibov. Westen. 294-301.REFERENCES Maj. A. Chapter 1: Diagnositc Controversies in American Psychiatric Press Review of Psychiatry. (2005). Tasman. Bradley B. Introduction to the Special Section: Toward a Dimensionally Based Taxonomy of Psychopathology . DH. Multiaxial Diagnostic Approach in Diagnosis and Assessment in Autism (Eds Schopler E.int www. Watson. 2005 November . An Empirically Based Prototype Diagnostic System for DSM V and ICD 11. DP.org Krueger.who. (2011). J Abnorm Psychol.Vol 21(3). (1992).
This action might not be possible to undo. Are you sure you want to continue?
We've moved you to where you read on your other device.
Get the full title to continue reading from where you left off, or restart the preview.