Tag Archives: DSM

Comparing the DSM and the Oxford Textbook of Psychopathology


Comparing the styles of the DSM and the Oxford Textbook of Psychopathology helped me to see how different people can interpret the same information.  I was actually surprised to see the difference between the two books because I thought they would have been much more similar.

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The DSM first shows a list of the ten specific personality disorders with a brief description of each of them, it then describes the three clusters and which of the clusters each disorder fits into, and this is decided by the disorder’s description.  After the definitions, the DSM explains the diagnostic features and how personality traits fit into them and the various criteria associated with personality disorders.  After the chapter gives information about a patient’s background regarding a personality disorder.  It explains the dimensional models where it tells about the effort to find the most important factors in what is considered to be normal behavior.

Once through the introductory information, the DSM begins with Cluster A personality disorders which include paranoid personality disorder, schizoid personality disorder, and schizotypal personality disorder.  Cluster B personality disorders which include antisocial personality disorder, borderline personality disorder, histrionic personality disorder, and narcissistic personality disorder.  Cluster C personality disorders include avoidant personality disorder, dependent personality disorder, obsessive-compulsive personality disorder, and personality disorder not otherwise specified.

Each disorder description includes a more in depth description and it gives other disorders that are most likely to co-occur, a more specific description of culture, age and gender features which gives more insight into the background of the person experiencing the personality disorder, it gives a small description of how many people in the population are generally affected and an in depth look at how you can tell the difference between this disorder and others that are considered similar.  At the end of the disorder description is a list of criteria specific to that disorder.

The Oxford Textbook of Psychopathology provides the information in a different layout.  This text lists out explanations of disorders in groupings like the DSM, but the groupings are what the text calls “a loose progression that ranges from the prescientific or naïve to what is deemed progressively more scientific” (Blaney, P.H., Millon, T.).  There are four categories that the text displays, these are categorical versus dimensional versus prototypal structural models, mathematical methods of data analysis, theoretical conceptions of personality, and evolutionary theories of personality.  Each category lists out several subheadings, so far instance under the first heading, categorical versus dimensional versus prototypal structural models there is a subheading titles.  The categorical model, which tells us the traditional thought of personality types, how a group of experts gets together and make decisions about how the science will work in this area, and taximetrics, which tells us the basic steps being taken to identify how a personality type would come about in a person and how it would be recognized.  This heading then goes on to discuss the dimensional model, and prototypal models.

Next is the mathematical methods of data analysis which helps to define which characteristics are most important to a personality disorder.  It explains that there are two completely different ways to find these, which are theoretically and methodologically and then lists five different models that help with this process.

Each heading is formatted in a similar manner, but does not give any specific disorders that could or would be attached to it.  This would be the main difference between the DSM and our text.  The most obvious similarities are that they each use groupings for the various categories and then define each subject in the grouping.

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I like the way the DSM is formatted because it gives general guidelines and then gets more specific about each specific disorder.  I like the way it shows the characteristics of the disorder instead of a history of the various ways of thinking about the disorders.

Sexual Dysfunction vs. Sexual Disorder


A “dysfunction” is literally defined as an abnormality or disturbance of function.  (Colman, 2009, p. 232)  It may also be defined as abnormal or unhealthy interpersonal behavior or interactions.  (Merriam-Webster Online Dictionary [MWOD], 2010)  Specifically, sexual dysfunctions are defined as “conditions that impair the desire or ability to achieve sexual satisfaction.”  (Blaney & Millon, 2009, p. 399)  With and within the DSM-IV-TR, the term sexual dysfunction is conceptualized as an umbrella category that encompasses a wide variety of sex related conditions, some of which may or may not “belong” in a manual that is intended to cover and contain “mental disorders.”  This essay will give a brief overview of what are currently considered under the broad title of Sexual Dysfunctions, and provide some subjective thought on efficacy of continued inclusion as we move toward the newest revision of the “psychiatric bible,” the DSM-V.

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Under the rubric set forth by the current DSM, the DSM-IV-TR, the following disorders are considered under the broader category of Sexual Dysfunctions: Sexual Desire Disorders (i.e., Hypoactive Sexual Desire Disorder, Sexual Aversion Disorder), Sexual Arousal Disorders (i.e., Female Sexual Arousal Disorder, Male Erectile Disorder), and Orgasmic Disorders (i.e., Female Orgasmic Disorder, Male Orgasmic Disorder, and Premature Ejaculation), Sexual Pain Disorders (i.e., Dyspareunia, Vaginismus), Sexual Dysfunction Due to a General Medical Condition, Substance-Induced Sexual Dysfunction, and Sexual Dysfunction Not Otherwise Specified (NOS).  (4th ed., text rev.; DSM-IV-TR; American Psychiatric Association, 2000, p. 535)  Comparatively speaking, a “disorder” is literally defined as an abnormal physical or mental condition.  (MWOD, 2010)  In the DSM-IV-TR, sexual dysfunctions are differentiated from Paraphilias and Gender Identity Disorders (GIDs).  The essential features of a Paraphilia are arousing fantasies, sexual urges, or behaviors generally involving non-hum, the suffering or humiliation of oneself or one’s partner, or children or other non-consenting persons.  (4th ed., text rev.; DSM-IV-TR; American Psychiatric Association, 2000, p. 566)  Paraphilias include Exhibitionism, Fetishism, Frotteurism, Pedophilia, Sexual Sadism, Transvestic Fetishism, Voyeurism, and Paraphilia NOS.  Conversely, GID is characterized by strong and persistent cross-gender identification coupled with a persistent discomfort about one’s assigned sex and/or gender role.  (4th ed., text rev.; DSM-IV-TR; American Psychiatric Association, 2000, p. 576)

Among those disorders, there are some that appear to fit better than others.  Take the Sexual Desire Disorders (i.e., Hypoactive Sexual Desire Disorder, Sexual Aversion Disorder) for example… what is considered normal libido?  Is there any objective way to quantify or qualify the need or desire to have sexual relations?  Honestly, I don’t think there is.  What is normal sexual activity to me and my partner may be too much or too little for another.  Like most disorders, one of the key diagnostic criterions of the DSM-IV-TR sexual dysfunctions is “marked distress or interpersonal difficulty.”  As a result, it’s not a problem unless the potential client makes it one, regardless of the presence of desire to engage in sexual activity.  Furthermore, it’s not a disorder unless a deficiency is detected and deemed appropriate by the clinician, thereby inserting another level of subjectivity.  It should come as no surprise that inter-rater reliability is lacking, and epidemiological data is mixed based on the definition of the disorder.

Another example is Sexual Arousal Disorders (i.e., Female Sexual Arousal Disorder, Male Erectile Disorder).  Although at the core, there may be some genetic or psychological factors at play, I am not sure I could consider it a disorder if someone simply isn’t attracted to their potential partner?  There are so many variables at play in Female Sexual Arousal Disorder that it may be increasing difficult to identify specific etiology.  Perhaps her partner is less than skilled.  Perhaps there is a developmental basis for the lack of lubrication (menopause).  Perhaps there are underlying biological causes in the form of circulatory problems that contribute to an inability to attain sufficient swelling response during periods of sexual arousal.  All of these situations are in fact treatable, but should we consider them “mental disorders?”  In some cases yes, where psychological factors are at play… however, there are an abundance of situations where psychological factors have little relevance in the diagnosis and treatment of Sexual Arousal Disorders.

Orgasmic Disorders (i.e., Female Orgasmic Disorder, Male Orgasmic Disorder, and Premature Ejaculation) may be propagated by psychological factors, and subsequently appropriate for inclusion in the DSM-V.  Conversely, there are a whole host of “combined factors,” including a very wide variability in type or intensity of stimulation that can trigger organism, that are likely less than “psychological” in nature.  Take premature ejaculation for example.  I think we would be hard pressed to find men who don’t want to last longer… and that inability may be a significant cause of duress for some men.  But as currently envisioned, there is no baseline as to what constitutes a threshold between a disorder, and simply being “excitable.”

Paraphilias are a hot topic in the psychological community because the presence of “mental disorders” like pedophilia seems to justify the behavior.  It would appear to me that any suggestion that paraphilias are in fact a mental disorder would present the opportunity to present a legal argument that “he or she is mentally ill, and as a result, can’t be considered liable for these actions.  In my opinion, simply having a legal option like that is counterintuitive and reprehensible.

We have addressed what is present; however, there is one glaring absence in the current nosology.  Where is the diagnostic category of “sexual dysfunction due to mental disorder?”  One possible solution is to redefine sexual dysfunction due to substance abuse as a dysfunction due to mental disorder “with onset during intoxication.”  (Segraves & Balon, 2007)  Including such a category would be intuitive in my opinion, despite the fact that our meanings of the words disorder and dysfunction have become rather convoluted in their practical application.  It seems to meet the definition of “abnormal or unhealthy,” more so than some of what we currently consider to be dysfunctions.  Without, there is a great deal of work that needs to be done in terms of clarification and codification as we approach the watershed appearance of the latest version of the DSM.

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References

American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed., text rev.). Washington, DC: Author.

Blaney, P. H., & Millon, T. (2009). Oxford textbook of psychopathology (2nd ed.). New York, New York: Oxford University Press.

Colman, A. M. (2009). Oxford dictionary of psychology (3rd ed.). Oxford, NY: Oxford University Press.

Merriam-Webster Online Dictionary. (2010). disorder. Retrieved May 23, 2010, from http://www.merriam-webster.com/dictionary/disorder

Merriam-Webster Online Dictionary. (2010). dysfunction. Retrieved May 23, 2010, from http://www.merriam-webster.com/dictionary/dysfunction

Segraves, R. T., & Balon, R. (2007, Aug). Toward an improved nosology of sexual dysfunctions in DSM-V. Psychiatric Times, 24(9), 44. Retrieved from http://ezproxy.bellevue.edu:80/login?url=http://proquest.umi.com.ezproxy.bellevue.edu/pqdweb?did=1313390581&Fmt=2&clientId=4683&RQT=309&VName=PQD

Controversies Surrounding Classification


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The history and evolution of the Diagnostic and Statistical Manual of Mental Disorders (DSM) has taken many twists and turns in its 58 year history.  Its recent ascension to preeminence, as the multi-disciplinary diagnostic tool of choice, has brought it under no small amount of scrutiny.  It could be argued that one reason for that ascension is that its contributors, including Dr. Robert L. Spitzer, have gone to great lengths to make it as atheoretical as possible. Atheoretical, defined as “not based on or concerned with theory.”  (http://www.merriam-webster.com/)  Without, the proposition that our current diagnostic “bible” is atheoretical is theme that is under a great deal of scrutiny, and can certainly be disputed from a number of different perspectives.

Before we delve into the DSM itself, let us consider the title.  It is clear that ‘mental disorder’ is a technical term, because people do not normally use it in nontechnical, everyday social interactions. It is a term coined by scientists to serve a certain function in science. So the question is whether specialists use it to express an ordinary or a technical concept; and, if the latter is the case, whether that concept is theory laden. But these are quite difficult questions, for specialists happen to disagree on what concept the technical term ‘mental disorder’ should express. (Gaete, 2008)  Thus, it could be argued that the selection of the term ‘mental disorder’, by nature of its origin as a technical term, gives rise to an underlying theoretical basis that gives the meaning the definition; thereby making the theoretical neutrality of the DSM impossible.  Hence, there is considerable discontent about what constitutes a ‘mental disorder,’ and that definition is essentially determined is made by a community who is not atheoretical by nature.

Nonetheless, an atheoretical attempt was made.  With the 1980 revision of the DSM-III, Spitzer and associates acknowledged sensitivity to the division between psychoanalytic and biological explanations of mental disorders.  Consequently, the determination was made that the DSM-III would be theory neutral in order for the classification to be more accessible to all mental health professionals.  (Blaney & Millon, 2009, p. 44)

There is sentiment, however, that the lack of a theoretical foundation stymies the progress of all the disciplines that employ the DSM-III and its predecessors.  If all of the principal clinical syndromes or personality disorders could be logically derived from a systematic theoretical foundation, this would greatly facilitate an understanding of psychopathology, organize this knowledge in an orderly and consistent fashion, and connect the data it provides to other realms of psychological theory and research, where they could then be subjected to empirical verification or falsification.  (Millon, 2000, para. 1)  The real question remains, if we choose a framework, which framework should we choose?

Some would suggest that we not possibly “carve nature at the joints,” as Millon suggests, if we continue to delude ourselves with a top-down approach to taxonomy.  Essentialist top-down ‘expert-driven’ approaches to taxonomy were rejected in the biological sciences in the 18th and 19th centuries.  They are flawed because they are based on the unsupportable assumption that it is possible, a priori, to know the true essence of a category.  We cannot develop a progressive scientifically based nosology shaped by a single expert-driven conception of psychiatric illness no matter how wise its advocate.  (Kendler, 2009)

Instead, Kendler would suggest we move toward a broader reaching, empirical, bottom-up nosology.  If our current methods for validating psychiatric disorders, including description, genetics, imaging, treatment response and follow-up studies, reflect aspects of an objective truth out there in the world and we want our nosology to describe those truths with increasing accuracy, the only way to achieve this is to assure ourselves that each periodic revision of our manuals contains improvements on its predecessor. That is, changes are only made on the basis of convincing evidence that, using an agreed upon set of validators, the new diagnostic criteria improve upon the performance of their predecessor. (Kendler, 2009)

In closing, we should consider carefully our changes to the upcoming revision of the DSM.  We should be conscious of the “top-down” nosological framework of classification and make rational attempts to challenge those top-down assumptions in our daily clinical experiences.  And finally, we should consider the ramifications of the clinical definitions and concepts that we use to convey the details of our findings.  Perhaps, after this discussion, we can conclude that Dr. Carole Patrick was right… there are no value free definitions.  (Patrick)

References

Blaney, P. H., & Millon, T. (2009). Oxford textbook of psychopathology (2nd ed.). New York, New York: Oxford University Press.

Corey, G., Schneider-Corey, M., & Callanan, P. (2007). Issues and ethics in the helping professions (8th  ed.). Belmont, CA: Brooks/Cole.

Gaete, A. (2008, Dec). The concept of mental disorder: A Proposal. Philosophy, Psychiatry & Psychology : PPP, 15(4), 327-340. Retrieved from http://ezproxy.bellevue.edu:80/login?url=http://proquest.umi.com.ezproxy.bellevue.edu/pqdweb?did=1759881121&sid=4&Fmt=3&clientId=4683&RQT=309&VName=PQD

Kendler, K. S. (2009, Dec). An historical framework for psychiatric nosology.  Psychological Medicine, 39(12), 1935-1942. Retrieved from http://ezproxy.bellevue.edu:80/login?url=http://proquest.umi.com.ezproxy.bellevue.edu/pqdweb?did=1939354861&sid=3&Fmt=3&clientId=4683&RQT=309&VName=PQD

Millon, T. (2000, Spring). Reflections on the future of DSM axis II.  Journal of Personality Disorders, 14(1), 30-42. Retrieved from http://ezproxy.bellevue.edu:80/login?url=http://proquest.umi.com.ezproxy.bellevue.edu/pqdweb?did=52013136&sid=2&Fmt=4&clientId=4683&RQT=309&VName=PQD

Patrick, C. (Producer). (n.d.). Defining abnormality video [Webcast]. Available from http://idcontent.bellevue.edu/content/CAS/HS/513/hs513abnormality.html.

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