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Chapter 3

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Konstantine Zakzanis

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 accepted.  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 DSM-IV-TR)  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 loved one). 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 retardation 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 information.  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. Diagnostic Categories  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 for parents  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 Substance-Related Disorders  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. Schizophrenia  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. Mood Disorders  These diagnoses are applied to people whose moods are extremely high or extremely low.  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 of self-reproach.  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  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 Somatoform Disorders:  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 consulted doctors  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 pain  Hypochondriasis: the misinterpretation of minor physical sensation of serious illnesses  Dysmorphic disorder: people with this disorder are preoccupied with an imagined defect in their appearance Dissociative Disorders  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 Sleep Disorders  Dyssomnias: sleep is disturbed in amount, quality, or timing  Parasomnias: unusual event occurs during sleep(e.g. sleepwalking) Eating Disorders  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 laxatives Factitio
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