Chapter 3: Classification and Diagnosis
A Brief History of Classification
Early Efforts at Classification
During the 19th and early 20th centuries, there was great inconsistency and
classification of abnormal behavior.
By the end of the 19th century, the diversity of classifications has recognized
as a serious problem that impeded communication among people in the field
and several attempts were made to produce a system of classification that
would likely be adopted.
In the UK as well as in Paris, they've produced a classification scheme that
was never widely used.
Development of the WHO and the DSM Systems
The world health organization added mental disorders to the International
List of Causes of Death. However the mental disorders section was not widely
The American psychiatric Association published its own diagnostic and
statistical manual. The World Health Organization published a new
classification system knows more widely accepted. It was the second version
of the American psychiatric Association.
Furthermore the American psychiatric Association published and extensively
revised diagnostic manual, a third edition.
In 1988, the American psychiatric Association appointed a task force, chaired
by psychiatrist Allen Frances, to begin work on the DSM IV. Many
psychologists were established to review sections of the DSM-III, prepare
literature reviews, analyze previously collected data and collect new data is
needed. More than 2 dozens Canadian psychologists and psychiatrists sat on
the DSM-IV committees and participated in consultation.
DSM-IV is used throughout the US and Canada and is becoming widely
accepted around much of the world.
The fourth version of the DSM was published in 1994. The American
psychiatric Association and subsequently completed a text revision called the
DSM-IV-TR. This revised version contains few changes; some sections were
rewritten to enhance clarity and incorporate recent research findings related
to issues such as prevalence, course, and etiology of disorders.
The DSM is controversial. For some, it is not the book of truth about
psychological problems, nor is it universally embraced by psychiatrists,
psychologist, and others in the field.
Most psychiatric diagnoses are not identical to medical diagnosis where the
basic cause is frequently known and the presence of the disease can usually
be objectively determined.
The Current Diagnostic System of the American Psychiatric Association (DSM-IV and
The term " mental disorder” is problematic and that no definition adequately
specifies precise boundaries for the concept.
The DSM-IV-TR defines mental disorder as: o a clinically significant behavioral or psychological syndrome or
pattern that occurs in an individual and that is associated with
present distress or disability or with a significant increased risk of
suffering death, pain, disability, or an important loss of freedom.
o This syndrome or patent must not be merely an expectable and
culturally sanctioned response to a particular event (e.g. the death of a
o What ever its original cause, it must currently be considered a
manifestation of a behavioral, psychological, or biological dysfunction
in the individual.
Five Dimensions of Classification
The most sweeping change from the DSM-III is the use of multi-axial
classification, whereby each individual is rated on five separate dimensions,
or axes. The five axes include:
1. Axis I: All diagnostic categories except personality disorders and mental
2. Axis II: Personality disorders and mental retardation
3. Axis III: General medical condition
4. Axis IV: Psychosocial and environmental problems
5. Axis V: Current level of functioning
This system forces the diagnostician to consider a broad range of
Axis one and two compose the classification of abnormal behavior.
The separation of axis one and two functions to ensure that the presence of
long-term disturbances is not overlooked. For example, most people consult
a mental health professional for axis 1 condition like depression, but prior to
the onset of their axis one condition, they may have had axis 2 conditions
such as dependent personality disorder.
The separation of these two axes is meant to encourage clinicians to be
attentive to the possibility of two conditions coexisting. The presence ofan
axis II disorder along with an axis one disorder generally means that the
person's problems will be more difficult to treat. On axis III, the clinician
indicates any general medical conditions believed to be relevant to the
mental disorder in question. For example, the existence of a heart condition
and a person was also being diagnosed with depression would have
important implications for treatment.
Axis 4 codes for psychosocial and environmental problems that the person
has been experiencing and that may be contributing to the disorder. These
include occupational problems, economic problems, interpersonal difficulties
with family members and a variety of problems and other life areas that may
influence psychological functioning.
Take note that for many of the disorders, the DSM indicates that the disorder
may be due to a medical condition or substance abuse. Clinicians must therefore be sensitive not only to the symptoms of their
clients, but also to the possible medical causes of their clients’ conditions.
Disorders Usually First Diagnosed in Infancy, Childhood, or Adolescence
Separation anxiety disorder: excessive anxiety about being away from home
Conduct disorder: children repeatedly violate social norms and rules
Attention deficit hyperactivity disorder: individuals who have difficulty
sustaining attention and are unable to control their activity when the
situation calls for it
Mental retardation: as listed on axis II; individuals who show sub normal
intellectual functioning and deficits in adaptive functioning
Pervasive developmental disorders: this includes autistic disorder, a severe
condition in which the individual has problems in acquiring communication
skills in deficit and relating to other people
Learning disorders: refer to delays in acquisition of speech, reading,
arithmetic, and writing skills
A substance-related disorder is diagnosed when the ingestion of some
substance – alcohol, opiates, cocaine, and amphetamines-has changed
behavior enough to impair social or occupational functioning.
The individual may become unable to control or discontinue ingestion of the
substance and may develop withdrawal symptoms if he or she stops using.
These substances may also cause or contribute to the development of other
axis one disorders, such as mood or anxiety disorders.
For patients, contact with reality is faulty.
Their language and communication are disordered, and they may shift from
one subject to another in ways that make them difficult to understand.
They may experience delusions, such as believing that thoughts that are not
their own have been placed in their heads.
They may be plagued by visual and auditory hallucinations.
Their emotions are blunted, or inappropriate and or social relationships and
ability to work show marked deterioration.
These diagnoses are applied to people whose moods are extremely high or
Major depressive disorder: the person is deeply sad and discouraged and is
also likely to loose weight and energy and have suicidal thoughts and feelings
Mania: exceedingly euphoric, irritable, more active than usual, distractible,
and processed of unrealistically high self-esteem
Bipolar disorder: experience of episodes of mania of mania and depression
Anxiety disorders have some form of irrational overblown fear as the central
disturbance Phobias: fear of an object or situation so intensely that they must avoid it
although the individual know that their fear is unwarranted and
unreasonable and disrupts their lives
Panic disorder: a person is subject to sudden but brief attacks of intense
apprehension, so upsetting that he or she is likely to tremble, shape, feel
dizzy, and have trouble breathing. This disorder may be accompanied by
agoraphobia (fearful of leaving familiar surroundings)
Generalized anxiety disorder: fear and apprehension are pervasive,
persistent, and uncontrollable. They worry constantly, feel generally on edge,
and are easily tired
Obsessive-compulsive disorder: persistent obsessions or compulsions. An
obsession is a recurring thought, idea, or image that uncontrollably
dominates a person's consciousness. A compulsion is an urge to perform a
stereotype, with the usually possible purpose of warding off an impending
feared situation. Attempts to resist the compulsion create so much tension
that the individual usually yields to it.
Post traumatic stress disorder: experiencing anxiety and emotional
numbness in the aftermath of a very traumatic event. Individuals have
painful, intrusive recollections by day and dreams at night. It is difficult for
them to concentrate and feel detached from others and from ongoing affairs.
Acute stress disorder: similar to post traumatic stress disorder, but the
symptoms do not last as long
Physical symptoms of somatoform disorders have no known physiological
cause but seem to serve the psychological purpose
Somatization disorder: people with this disorder have a long history of
multiple physical complaints for which they have taken medicine or
Conversion disorder, people with this disorder report the loss of motor or
sensory function, such as paralysis, and anesthesia, or blindness
Pain disorder: people with this disorder suffer from severe and prolonged
Hypochondriasis: the misinterpretation of minor physical sensation of
Dysmorphic disorder: people with this disorder are preoccupied with an
imagined defect in their appearance
Psychological dissociation is a sudden alteration in consciousness that affects
memory and identity
Dissociative amnesia: people with this disorder may forget their entire past
or lose their memory for particular time period
Dissociative fugue: the individual suddenly and unexpectedly travels to a
new locale, starting new life and cannot remember his or her previous
identity Dissociative identity disorder: people with this disorder possess two or more
distinct personalities, each complex and dominant one time
Depersonalization disorder: a severe and disrupted feeling of self-
estrangement or unreality
Sexual and Gender Identity Disorders
Sexual disorders from the DSM-IV-TR list three principal subcategories:
o Paraphilia: the source of sexual gratification-as in exhibitionism,
sadism and masochism- unconventional
o Sexual dysfunctions: unable to complete the usual sexual response
cycle. Inability to maintain an erection, premature ejaculation, and
inhibition of orgasm are examples of their problems
o Gender identity disorder: extreme discomfort with their anatomical
sex and identify themselves as members of the opposite sex
Dyssomnias: sleep is disturbed in amount, quality, or timing
Parasomnias: unusual event occurs during sleep(e.g. sleepwalking)
Anorexia nervosa: the person avoids eating and becomes emaciated
Bulimia nervosa: frequent episodes of binge eating are coupled with
compensatory activities such as self-induced vomiting and heavy use of