What is Abnormal Behavior?
- Psychopathologist: Scientist that studies the cause of mental disorders and the factors that influence its development.
- Hard to define abnormal behavior—a. no single descriptive feature is shared by all abnormal behavior, no one criteria are sufficient to define abnormal behavior and b. there is no discrete boundary between abnormal and normal behavior.
Definition 1 of Abnormal Psychology: Statistical Infrequency or Violation of Social Norms
- Person whose behavior is deviant or non-conforming is likely to be noted as “abnormal”.
- Statistical infrequency—difference from the norm in a very low IQ score (ex: score of 64)
- Violation of social norms—dressing different from typical girls or women
Definition 1: Advantages of the Statistical Infrequency or Violation of Social Norms Definition
- Cutoff Points: Has cutoff marks that are quantitative (a low score can be compared to the cutoff point). Ex: Used to compare psychological test-scores (above the cutoff is clinically significant).
- Intuitive Appeal: Behaviors that we consider abnormal would be judged as abnormal by others.
Definition 1: Problems of the Statistical Infrequency or Violation of Social Norms Definition
- Choice of Cutoff Point: Conformity criteria are limited as it is difficult to establish cutoff points. Very few guidelines on how to form cutoff points. Shouldn't categorize every abnormality as deviant.
- The Number of Deviations: How many deviant behaviors are needed to earn the label “deviant”?
- Cultural and Developmental Relativity: What is classified as deviant for one group, is not deviant for another. Also some behaviors that are appropriate at one developmental stage may be inappropriate at another (focus on comparison to same-age peers and not all-peers).
- Reducing cultural practices to the extreme (i.e. subcultures) is too much.
Definition 2 of Abnormal Psychology: Subjective Distress
- Subjective feelings and sense of well-being of the individual (ex: feeling happy, sad, troubled...).
Definition 2: Advantages and Problems of Subjective Distress Definition
- Individuals are aware of their emotional experiences and can express them; harder for children.
- Labeling someone as maladjusted only works if their behavior is specified and their behavioral manifestations are stated.
- How much subjective distress is needed to be defined as “abnormal”?
Definition 3 of Abnormal Psychology: Disability, Dysfunction or Impairment
- Abnormal behavior must create a level of social (interpersonal) or occupational (educational) problem. Dysfunction in either one of these two areas.
o Ex: Lack of friendships due to lack of social relationships (social dysfunction)
o Ex: loss of one's job due to depression (occupational dysfunction)
Definition 3: Advantages and Problems of the Disability, Dysfunction or Impairment Definition
- Relatively little inference is needed; people seek treatment for social and work problems.
- Judgements regarding social and occupational dysfunction is relative not absolute (no standard).
o There are self-report inventories and interviews to assess work and social functioning.
What does this mean?
- No specific definition of 1,2 or 3 can be used as a standard to define abnormal behavior.
- Abnormal behavior does not equal mental illness
- Mental Illness: Frequently observed syndrome that are made up of certain abnormal behaviors.
Mental Illness Definition—What Does it Encompass?
- Behavioral or psychological syndrome (cluster of abnormal behaviors) must be linked to distress, disability or a risk of problems.
- Represents a dysfunction within an individual
- Not all deviant behavior or conflicts in society are indicative of a mental disorder (ex: cultural, religious, sexual deviance).
The Importance of Diagnosis
- Diagnosis is a type of categorization; categorization allows us to make distinctions for survival.
- Advantages of Diagnosis:
- Communication—conveyed through a diagnostic term (“verbal shorthand”)
o Standardized criteria allow for comparison across states (ex: California vs. Texas) and clinicians.
o DSM criteria for mental disorders are useful for communication as they are descriptive (no specific theoretical focus).
- Diagnosis promotes empirical research in psychopathology
o Comparison between groups (ex: psychological test performance or personality).
- Standard diagnostic criteria allow for research into the etiology/causes of abnormal behavior o Placing individuals in groups with individuals that share the same diagnostic features.
- Diagnosis allows/suggests which model of treatment is most likely to be effective
Early Classification Systems
*Emil Kraepelin—father of modern systems of psychiatric diagnostic criteria
- 1889—Congress of Mental Science adopted a classification system in Paris.
- 1948—World Health Organization developed a classification system.
- 1952—American Psychiatric Association developed Diagnostic and Statistical Manual (DSM-I)
- 1980—DSM-III (Major change in diagnostic criteria)
Explicit diagnostic criteria for mental disorders was introduced
Use of a multi-axial system of diagnosis
Descriptive diagnostic approach (neutral to etiology theories)
o Greater focus on clinical utility of diagnostic system
- 1994—DSM-IV; published an additional DSM for children aged 0-3.
The Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR)
- Changes made in DSM-IV-TR was based far more on empirical data than was previous versions.
- Multiaxial Assessment: Complete diagnostic evaluation; clients are evaluated on 5 domains.
- Principal Diagnosis: Main diagnosis or condition for which patient seeks treatment
- Axis I: Clinical Disorders or Other Conditions (except personality disorder & mental retardation)
- Axis II: Personality Disorders and Mental Retardation
- Axis III: Medical Condition that are relevant to the treatment of Axis I and II
- Axis IV: Psychosocial and Environmental Problems
- Axis V: Global Assessment of Functioning (GAF) score on scale 1-100
General Issues in Classification
8 Main Issues: Categories versus Dimensions, Bases of Categorization, Pragmatics of Classification, Description, Reliability, Validity, Bias and Coverage.
Categories Versus Dimensions—Is present vs. absent appropriate or is a dimensional model better?
- Based on symptoms a patient is placed within a
- Easy to confuse categorization with explanation
- Abnormal behavior is not different from normal behavior but it falls along a dimension (degree).
- Category implies an all-or-nothing approach (present vs. absent) instead of using a dimension.
Bases of Categorization—Should there be multiple ways to make a diagnosis? Does this create too much heterogeneity within the diagnostic category?
- Diagnostic measures may be complicated requiring the clinician to know a wide variety of techniques.
- Membership in any one area is most likely going to be heterogeneous because there is multiple basis for diagnosis.
Pragmatics of Categorization—How do we decide if a condition is included in the diagnostic manual?
- Homosexuality was dropped from the DSM and regarded as a lifestyle (dropping from DSM was done through a psychiatric membership vote).
- DSM is crafted by committees. Members are from different backgrounds and constituencies.
Description—Are diagnostic category features properly described? Are diagnostic criteria specific and objective?
- DSM-IV provides detailed information for Axis I and II. Also provides information about each diagnosis including age of onset, course, prevalence, complications, family patterns.these features enhance reliability and validity.
Reliability—Are diagnostic judgements reliable & can different clinicians agree on a diagnosis?
- Refers to the consistency of diagnosis across raters; DSM III—specific criteria attempted to increase reliability of diagnosis.
- Developed structured diagnostic interviews that push clinicians to use specific DSM criteria; this had led to greater reliability.
- Even with structured interviews, reliability is not guaranteed (e.g. generalized anxiety disorder).
Validity—Can we make meaningful predictions based on our knowledge of an individual's diagnosis?
- If clinicians fail to agree on proper classification of patients then it can't be demonstrated that the classification system has meaningful correlates or has
- Establishing validity of a diagnostic criteria involves 5 steps (Robbins & Guze):
o Clinical description and features beyond the disorders symptoms (ex: demographic). o Laboratory studies—identify meaningful correlates of the diagnosis (ex: psych tests) o Delimitation from other disorders—homogeneity among clinicians o Follow-up studies—assess test-retest validity of diagnosis
o Family studies—determine if the disorder runs in the family.
Bias—Are DSM features biased due to gender, race, SES background? Are clinicians biased in their interpretations or application of the diagnostic criteria?
- The DSM system would be called into question if the same cluster of behaviors resulted in a diagnosis for one individual but not for another.
- Two areas of most bias—sex bias and race bias
- DSM has been regarded as a male centered system that overestimates pathology in females.
- For some diagnosis biological/cultural factors may influence which gender is diagnosed more (ex: antisocial personality disorder is more common in men).
- Clinicians may however be biased in the way they apply the diagnosis; but it does not indicate sex bias within the diagnostic criteria.
- Culture may influence diagnosis & treatment factors, “culture bound syndromes” (ex: koro, voodoo death) and if a patient decides to seek treatment or not.
Coverage—Does the DSM criteria apply to people that present with psychological or psychiatric treatment? Is the DSM too narrow or too broad in coverage?
- DSM-IV-TR has very descriptive and detailed diagnosis, but some feel that it may be too broad.
o Ex: childhood developmental disorders (i.e. dyslexia.) being labelled as mental disorder
- Other diagnosis: “premenstrual dysphoric disorder”—may be used against women.
- Mental disorders use terms like disorder, symptom, condition, and suffers from make it seem like the person has a disease.
- Diagnosis can be stigmatizing to the labeled individual and it is also why people do not seek treatment.
- Observers see the label not the person (ex: can damage relations, employment opportunity).
The Diathesis-Stress Model
- Diathesis: Vulnerability or predisposition to develop a disorder (can be biological or psychological).
o Necessary but not sufficient for a disorder; added component is stress.
- Stress can be environmental (ex: abuse), biological (ex: poor nutrition), interpersonal (ex: bad marriage) or psychological (ex: bad family environment).
- Diathesis can influence perception of stress (one event can be more stressful for someone than another).
- Diathesis also influences person's own life course and choice experiences.
- Both Diathesis + Stress is needed^ disorder
o High diathesis and high-moderate stress levels greater likelihood of disorder.
Value of Classification
- Categorization allow us to generalize and predict
- DSM has been accused of being used more by clinical research than clinical practice.