Making Diagnoses Using the DSM
We have now described the information a clinician would gather in moving toward a diagnosis. But what form will the diagnosis take? In the last 50 years, the answer has typically come from either of two classification schemes: the InternationalClassification of Diseases (ICD-10), published by the World Health Organization andused mainly in Europe, and the DSM, published by the American Psychiatric Association and used as the standard guide in the United States. We will focus here on the DSM, because research in psychopathology (research that examines the causes and treatments of mental disorders) is almost always guided by the defi-nitions provided by the DSM.
The first edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-I) was published in 1952; since then, the manual has been reviewed and revised several times. In particular, the DSM-III, published in 1980, was heavily revamped to emphasize the specific signs and symptoms required for each diagnosis, holding theory to the side as much as possible. Subsequent revisions (including the most recent, DSM-IV-TR, published in 2000) have continued this trend, as will the next edition (DSM-V), which is due out in 2012. In addition, some terms (“neurosis”) have been dropped as not meaningful, and some diagnostic labels (“hysteria”) have been largely abandoned. Moreover, some disorders have been eliminated altogether—with the most prominent example being homosexuality. Until DSM-III, homosexuality was counted as a “disorder” to be “diagnosed.” For the last 30 years, though, the successive editions of DSM have abandoned this position as indefensible, and modern psychologists no longer count homosexuality as a “disorder” in any sense.
Across all of its editions, the DSM has tackled a crucial clinical question—namely, how severe does a set of symptoms have to be before it merits a diagnosis? After all, every one of us sometimes feels sad; how long must the sadness last and what other symptoms must be present for this to count as depression? Every one of us sometimes feels fearful; under what circumstances should feelings of fear be counted as a phobia? As we will see in the following sections, the DSM-IV-TR addresses these issues by setting out specific criteria for each disorder—often in terms of a particular duration for the symptoms, or a certain frequency.
Using the DSM, a clinician evaluates an individual with reference to five axes, or dimensions of functioning. The first two axes are designed to describe an individual’s current psychological condition: Axis I describes clinical syndromes such as depres-sion, eating disorders, and drug dependence. Axis II describes two broad sets of diffi-culties: mental retardation and personality disorders (such as antisocial personality disorder). Axis III is concerned with general medical conditions that may contribute to a person’s psychological functioning (such as constant pain from a continuing medical problem). Axis IV assesses social or environmental problems (including family or legal difficulties), and Axis V provides a global assessment of functioning—that is, how well a person is coping with her overall situation.
The current version of the DSM also includes, as an appendix, disorders that seem to appear in only some cultures. These culture-specific disorders include dhat, a term used in India to refer to severe anxiety about the discharge of semen; shenjingshauiro, a diagnosis in China characterized by fatigue, dizziness, and headaches;and ghost sickness, a powerful preoccupation with death found among some Native American tribes. Despite this nod toward cultural context, even some of the disor-ders listed in the main section of the DSM may be culture-bound—for example, bulimia nervosa, an eating disorder that we will consider later, seems to appear only in Western cultures or in cultures that have been heavily exposed to the West (Smith, Spillane, & Annus, 2006). It may well be that all of the DSM’s diagnostic categories are best understood in terms of their cultural setting—a point that’s certainly in line with the DSM’s broad definition of what a “mental disorder ” actually is.
Our discussion will focus largely on the Axis I classifications, although we will also say a little about Axis II. We will emphasize just a handful of the diagnostic categories. Nonetheless, the mental disorders we will discuss are persistent and prominent sources of human suffering. Studying how psychologists think about and try to explain them will help us to understand how they approach the other 200 or so disorders included in the DSM.
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