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Discussion Read ” Psychopathology and Use of the Diagnostic and Statistical Manual of Mental Disorders” by Cherry, Jacobs, Thornberry, and Gillaspy from Yo

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Discussion Read ” Psychopathology and Use of the Diagnostic and Statistical Manual of Mental Disorders” by Cherry, Jacobs, Thornberry, and Gillaspy from Your Practicum in Psychology: A Guide for Maximizing Knowledge and Competence (2015

This Mental Health and Wellness (MHW) curriculum is not intended for you to learn how to diagnose clients, rather to be familiar with the various mental disorders that can impact one’s life. In reviewing the article by Cherry related to an overview of the DSM5, please select one disorder you are interested in (ideally, one that hasn’t been discussed by another student yet) and provide your classmates with a practical overview of the disorder (to include associated adjustment and family problems, behavioral problems, and target characteristics, and stressors or trauma that may impact the diagnosis). Please include at least one additional reputable source that you used to describe your disorder. 75

Amanda S. Cherry, Noel J. Jacobs, Timothy S. Thornberry Jr.,
and Stephen R. Gillaspy

Psychopathology and Use
of the Diagnostic and
Statistical Manual of

Mental Disorders

5

he purpose of this chapter is to provide a brief summary and
review of diagnostic terms that you may encounter in your
courses and as you read patient files during your practi-
cum experiences. We start with a brief history of diagnostic
systems and then proceed to a review of the Diagnostic and
Statistical Manual of Mental Disorders (DSM), which is intended
to provide a quick reference to general diagnostic criteria
so that you will be able to better understand the diagnosed
disorders of the patients with whom you come into contact.
Additionally, this overview will assist you in understanding
the criteria patients meet to reach a diagnosis for various
disorders. Finally, the conclusion of the chapter allows you
to test your clinical judgment with two case vignettes.

T

http://dx.doi.org/10.1037/14672-005
Your Practicum in Psychology: A Guide for Maximizing Knowledge and Competence,
Second Edition, J. R. Matthews and C. E. Walker (Editors)
Copyright © 2015 by the American Psychological Association. All rights
reserved.

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76 C h e r r y e t a l .

Diagnostic Systems—
A History

Appropriate classifications and diagnoses are imperative for understand-
ing patients, stimulating research, providing guidelines for empirically
supported treatments, and obtaining reimbursement for services. One
of the first documented attempts in classification of mental disorders
was the 1840 census, which included one single category of “idiocy/
insanity.” This was then expanded to seven categories for the 1880 census:
mania, melancholia, monomania, paresis, dementia, dipsomania, and
epilepsy (American Psychiatric Association, 2014a). However, one of
the earliest guides for diagnoses, Statistical Manual for the Use of Institutions
for the Insane, was developed in 1917 by the “Committee on Statistics,”
which was formed from the National Commission on Mental Hygiene
and a group now known as the American Psychiatric Association (Grob,
1991). During World War II, there was a major shift in the role of psychi-
atrist from mental institutions to assessing and treating soldiers. During
this period of war, the Medical 203 was developed as a classification sys-
tem issued as a “War Department Technical Bulletin” under the Auspices
of the Surgeon General (Houts, 2000). The committee involved in the
development of the Medical 203 was chaired by a brigadier general and
psychiatrist, William C. Menninger. In addition to chairing this commit-
tee, Menninger led a group of his colleagues in forming the Group for
Advancement of Psychiatry (Houts, 2000). The means to classify mental
health disorders further evolved in 1949 when the World Health
Organization (WHO) published the sixth edition of the International
Statistical Classification of Diseases (ICD–6; 2010), which included for the first
time a section on mental disorders (American Psychiatric Association,
2014a). However, the ICD–6 was designed for international application,
and therefore after this event an American Psychiatric Association com-
mittee was empowered to develop a version specific to the United States
as well as to standardize a system for classification. Thus, in 1950, the
committee undertook the process of reviewing and consulting to compile
the DSM. The initial version of the DSM (DSM–I) was approved in 1951
and published in 1952. Since that time, the DSM has undergone a process
of evolution with each edition.

DSM–I contained 106 diagnostic categories. This initial edition was
not well received because of its subjective nature. Therefore, the DSM–II,
released in 1968, had the aim of diagnostic accuracy and shifted to
a more distinct disease model. The major criticism of the second edi-
tion was the DSM’s dehumanization of patients because it was viewed
as treating conditions and not individuals. Then the DSM–III, released
in 1980, was geared toward improving epidemiological accuracy and

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77Psychopathology and Use of the Diagnostic and Statistical Manual

diagnostic validity, which became a guideline for insurance and
reimbursement for services. With the revised third edition, classifi-
cations of disorders were given to correspond with diagnostic coding
of the WHO’s ICD, which is the official medical coding system used
within the United States. The DSM–IV (American Psychiatric Associa-
tion, 1994) and DSM–IV–Text Revision (American Psychiatric Associa-
tion, 2000) continued to evolve with responses to epidemiology and
cultural diversity, as well as continue to correspond with the ICD codes.

As the authors of the DSM–IV attempted previously, the authors of
the DSM–5 have designed the book to give the clinician a conceptual
guide and a tool book for greater understanding and practical applica-
tion. Their goal in this new edition is to synthesize the latest medical
and behavioral research with the existing understanding of mental dis-
orders as it has been applied to clinical, pharmaceutical, legal, and social
work with individuals. As research and clinical practice have evolved
over time, new understandings (and new questions) have led to suc-
cessive editions of this manual seen by many as the “bible” of mental
health. However, the authors of each new edition try to make changes
that improve not just the utility of the manual itself but also the under-
standing of mental illness as a whole. This edition was organized as a
parallel diagnostic code manual to the medical diagnostic manual titled
the International Classification of Diseases, 10th Revision (ICD–10). Addi-
tionally, the authors of the DSM–5 have reorganized the groupings of
disorders and redefined and renamed other disorders in new ways to
“stimulate new clinical perspectives” (American Psychiatric Associa-
tion, 2013, p. xli). You will find, if you are somewhat versed in the
categories and disorder descriptions of the DSM–IV already, that the
new manual attempts to give more explicit consideration, even when
brief, to developmental experience, cultural influence, and risk factors
in the development and expression of emotional and behavioral diffi-
culties. One of the most obvious differences you will notice between the
previous and current editions is the elimination of the “axes” (used to
differentiate primary psychological disorders from mental retardation,
personality disorders, and primary health diagnoses) into a combined,
nonaxial list followed by a designation of important contextual or inter-
personal aspects of the difficulties that the patient is facing.

The DSM has undergone revisions into four editions since World
War II and has become a standard classification system used by psychia-
trists, other physicians, and mental health providers. It describes the
essential features and full range of mental health disorders. The most
current version, the DSM–5, was released in May 2013. The current ver-
sion, like its predecessors, has been challenged to appropriately define
and classify mental disorders.

Although this chapter focuses on DSM–5 definitions of mental
health disorders, one should be aware that other classification systems

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78 C h e r r y e t a l .

exist that will likely have a growing impact on psychological practice,
conceptualization, and research. Along with DSM–5, there exists the
previously mentioned ICD, now in its 10th revision (ICD–10) with
the 11th revision due in 2017. The American Psychological Associa-
tion (2009) offers a comparison of the DSM and ICD. ICD is a prod-
uct of the WHO and was the culmination of an international effort
from its inception. In contrast, DSM–III was initially characterized by
minimal international participation and was notably different from its
then-companion ICD–8. However, these different coding systems have
become more similar with subsequent iterations and increasing collabo-
ration between the two organizations.

Although it has been suggested that the DSM will eventually be
unjustifiable to maintain as a separate diagnostic system from ICD, it is
also suggested that DSM will continue to be useful because of its inclu-
sion of details of mental health disorders that will never be incorporated
in the ICD (American Psychological Association, 2009). The most recent
edition of the DSM attempts to maintain its utility in a health care system
that uses ICD codes for billing and reimbursement purposes. Accord-
ing to the DSM–5’s website (American Psychiatric Association, 2014b),
DSM–5 provides a dual code system, including ICD–9 and ICD–10 codes
with DSM–5 diagnoses, in an effort to provide sufficient information
needed to assign ICD–10 diagnoses to patients. It is also noteworthy
that ICD and DSM are intended for different audiences, with ICD focus-
ing on maximizing clinical utility for nonspecialist medical providers
(Stein, Lund, & Nesse, 2013). Thus, both systems will likely maintain
some utility in their respective professional groups. Psychologists are
considered to be included in this nonspecialist medical providers group
and therefore are required to use ICD codes under the Affordable Care
Act for insurance reimbursement purposes.

In addition to DSM and ICD, the National Institute of Mental Health
(NIMH) developed the Research Domain Criteria (RDoC) system in an
attempt to find the basic, universal components of disordered thought
and behavior and bolster research connecting clinical symptoms with
underlying neurobiological mechanisms (Doherty & Owen, 2014; Stein
et al., 2013). The RDoC system conceptualizes mental disorders as dis-
orders of neurocircuitry with a biopsychosocial influence. It is hoped
that the RDoC system will stimulate research that can help bridge the
gap in our understanding between what we observe in the clinic and
the biological and physiological substrates from which these symptoms
emerge (Stein et al., 2013). At present, NIMH is encouraging RDoC
research to remain independent of ICD and DSM work to minimize
restrictions in research direction (Doherty & Owen, 2014).

Stein et al. (2013) pointed out that all three of these classification
systems have their benefits and drawbacks and that a true understand-

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79Psychopathology and Use of the Diagnostic and Statistical Manual

ing of mental health concerns, an understanding that considers the
contexts of global and public mental health, heterogeneous presenta-
tions, and multicausality, will require an understanding of all three of
these systems. They posited that for one to gain a better understanding
of psychopathology and its treatment, one must analyze the complex,
multilevel mechanisms of mental disorders emphasized by all of these
classification systems.

Neurodevelopmental Disorders

The group of conditions with an onset during childhood is qualified as
neurodevelopmental disorders. This qualification is primarily due to the
nature of the disorders’ manifestations early in development and may
include developmental deficits involving personal, social, academic,
and occupational functioning. Within this group, the range of develop-
mental deficits can vary from global impairments in social skills or intel-
lectual functioning to very specific limitations in learning or control of
executive functioning. Included within this category are disorders char-
acterized by deficits in intellectual, communication, relational, motor,
and learning abilities.

For example, Intellectual Disability is one disorder within this group
that is characterized by generalized deficits in mental abilities, includ-
ing reasoning, problem solving, planning, abstract thinking, judgment,
academic learning, and experiential learning. The resulting impairment
in adaptive functioning of this disorder limits the individual in attain-
ing standards of personal independence and social responsibility in one
or more areas of daily living (e.g., communication, social, academic,
occupational functioning).

Another disorder in this group, Global Developmental Delay, which
can result in similar impairments, is diagnosed when expected develop-
mental milestones are not met in several areas of functioning. This diag-
nosis is often appropriate for individuals who are unable to undergo
standardized assessments of functioning, including young children who
are not old enough for such tests. Although intellectual disability occurs
in all races and cultures, it is important to consider the individual’s
cultural, ethnic, and linguistic background when assessing for such a
disability.

Disorders defined by communication difficulties also fall under the
umbrella of neurodevelopmental disorders due to onset early in life and
possible lifelong functional impairments. These include language dis-
order (deficits in the development and use of language), speech-sound
disorder (deficits in the development and use of speech), and social

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80 C h e r r y e t a l .

(pragmatic) communication disorder (deficits in the development and
use of social communication). Childhood-Onset Fluency Disorder is
also clustered with these communication disorders and is characterized
by disturbances in the motor production and normal fluency of speech.

Persistent deficits in social communication and interaction across
multiple settings characterize autistic spectrum disorder. These deficits
can include problems in social reciprocity, nonverbal communication,
and skills in developing and maintaining relationships. In addition to
these deficits in social communication, restricted, repetitive patterns
of behavior, interests, or activities are required to meet criteria for this
disorder. It is important to consider cultural differences in norms for
social interactions, nonverbal communication, and relationships. How-
ever, individuals with autism spectrum disorder are diagnosed due to
being markedly impaired against the norms of their individual culture.
Various specifiers are used to individualize and clearly communicate
individuals with this disorder.

Another neurodevelopmental disorder, Attention-Deficit/Hyper-
activity Disorder (ADHD), is characterized by impairments in attention,
disorganization, hyperactivity–impulsivity, or a combination of these.
Examples of problems in inattention and disorganization include diffi-
culty staying on task, losing things, and seeming not to listen, whereas
examples of hyperactivity–impulsivity include being overly active, fidget-
ing, difficulty staying seated, interrupting others, and difficulty waiting
turns. It is also expected that these symptoms are to be present at levels
excessive of age and developmental level. This disorder, although typi-
cally first appearing in childhood, can persist into adulthood with result-
ing impairments in social, academic, and occupational functioning.

Neurodevelopmental disorders involving deficits in motor abili-
ties include developmental coordination disorder, which is defined by
deficits in acquiring and executing coordinated motor skills. Individuals
with this disorder demonstrate clumsiness and slowness or inaccuracy
of motor skills, which result in interference in activities of daily living.
Individuals with repetitive, purposeless, and seemingly driven motor
behaviors that result in impairment in functioning are diagnosed with
Stereotypic Movement Disorder. Examples of such behavior include
body rocking, hand flapping, head banging, and self-biting. In con-
trast, individuals with motor or vocal tics (sudden, rapid, recurrent,
nonrhythmic, stereotyped motor movements or vocalizations) are
diagnosed within tic disorder diagnoses. Tourette disorder is diagnosed
when both motor and vocal tics are present for at least a year. Persistent
Motor or Vocal Tic Disorder is given when only motor tics or vocal tics
are present. Race, ethnicity, and culture may affect how tic disorders are
perceived and managed by a family and community, which can then
influence patterns of help seeking or acceptance of treatment choices.

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81Psychopathology and Use of the Diagnostic and Statistical Manual

Finally, among the neurodevelopmental disorders that entail defi-
cits in learning abilities is Specific Learning Disability. This diagnosis is
given when an individual experiences deficits in the ability to perceive
or process information efficiently and accurately in a specific area. As
a result, the individual’s performance in the affected academic area is
below average for age, level of education, or what is expected given
the individual’s intellectual abilities. This diagnosis typically manifests
early in the years of formal schooling and continues to cause impair-
ment in learning skills in reading, writing, or math (or a combination
of these) throughout schooling. Assessment for specific learning dis-
abilities should take into account the linguistic and cultural context of
the individual in addition to the individual’s educational and learning
history in the original culture and language.

Schizophrenia Spectrum
and Other Psychotic Disorders

Key features of diagnoses within the schizophrenia spectrum include
positive symptoms (delusions, hallucinations, disorganized thinking,
grossly disorganized or abnormal motor behavior) and negative symp-
toms. The positive symptoms of schizophrenia are referred to as positive
because their presentation is an excess in or distortion of the individu-
al’s normal functioning; negative symptoms refer to a decrease in or loss of
normal functions. Positive symptoms of schizophrenia are characterized
by disturbances in thinking, perceptions of reality, and disorganized
or abnormal behaviors. Delusions are defined as fixed beliefs that are
both false and unresponsive to change despite evidence against these
thoughts. Common content themes of delusions include persecutory,
referential (i.e., thinking certain environmental cues, such as a song
or a passage from a book, are directed at the individual), grandiose,
erotomanic, nihilistic, and somatic delusions. Hallucinations are per-
ceived experiences that occur with the absence of an external stimulus.
These experiences are vivid, clear, and lack voluntary control. However,
within some cultural contexts, hallucinations may be seen as a normal
part of a religious experience. The presence of disorganized thinking is
most commonly assumed from the individual’s speech as evidenced by
switching topics rapidly (derailment or loose associations), responding
in a tangential manner, or so disorganized that the person can hardly
be comprehended (e.g., word salad). Grossly disorganized or abnor-
mal behavior can include catatonia (i.e., unresponsiveness or stupor)
and can be manifest in a variety of ways and intensities. Finally, nega-
tive symptoms within the schizophrenia spectrum are characterized by

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82 C h e r r y e t a l .

mental abilities that the patient has lost or abilities that the patient can
no longer perform. Negative symptoms include diminished emotional
expression, including flattened affect, lack of eye contact, and intonation
in speech or nonverbal actions that give emphasis to speech; avolition,
which is a decrease in motivation to complete self-initiated purposeful
activities; alogia, which is a diminished speech output; anhedonia, or
decreased ability to perceive pleasure from positive stimuli; and asocial-
ity with a lack of interest in social interactions.

Delusional Disorder and Catatonia are two conditions defined by
abnormalities limited to one domain of psychosis (e.g., delusions and
grossly disorganized or abnormal behavior). Brief Psychotic Disorder,
Schizophreniform Disorder, and Schizophrenia are primarily differen-
tiated by duration in the abnormalities. Brief Psychotic Disorder has a
duration of more than 1 day but remits by 1 month; Schizophreniform
Disorder has a duration of less than 6 months; and schizophrenia lasts
for at least 6 months, and generally much longer, with at least 1 month
of having active symptoms.

Mood-Related Disorders

In regard to the following two sections of the DSM–5, Bipolar and
Related Disorders and Depressive Disorders, it is imperative to under-
stand the criteria required for meeting Manic, Hypomanic, and Major
Depressive Episodes.

A manic episode is characterized by a distinct period of abnormally
and persistently elevated, overly expansive mood, as well as abnor-
mally persistent and increased goal-directed activity or energy with a
duration of 1 week or longer. Three or more of the following symptoms
must also be present: inflated self-esteem or grandiosity, decreased need
for sleep, more talkative or pressured speech, racing thoughts, distracti-
bility, psychomotor agitation, and high-risk behaviors. A Manic episode
causes significant impairment in social or occupational functioning and
often requires hospitalization.

A Hypomanic Episode differs from a manic episode in duration and
severity. A Hypomanic Episode must last for at least 4 consecutive days
and does not cause marked impairment in social or occupational func-
tioning sufficient to require hospitalization.

A Major Depressive Episode has a minimum duration of 2 weeks
and includes five or more of the following symptoms: depressed mood,
marked or diminished interests or pleasure in activities, appetite distur-
bance, sleep disturbance, fatigue or loss of energy, diminished ability to
think or concentrate, and recurrent thoughts of death or suicide. These

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83Psychopathology and Use of the Diagnostic and Statistical Manual

symptoms also must be severe enough to cause significant impairment
in social and occupational functioning.

Bipolar and Related Disorders

To meet criteria for Bipolar I disorder, full criteria for at least one manic
episode must be met. Although it is not necessary to meet criteria for
a major depressive episode for a diagnosis of Bipolar I disorder, most
individuals with this disorder experience major depressive episodes. In
contrast, the diagnosis of Bipolar II disorder requires the experience
of at least one episode of hypomania and at least one episode of major
depression during the person’s lifetime. Because of their significant
mood instability, individuals with this disorder often experience signifi-
cant impairment in academic, work, and social functioning. For adults
experiencing at least 2 years’ duration of hypomanic and depressive
symptoms (1 full year for children) without meeting full criteria for a
mania, hypomania, or major depressive episode, a diagnosis of cyclo-
thymic disorder can be given.

Depressive Disorders

The presence of sad, empty, or irritable mood is the common feature of
the depressive disorders, which differ in terms of their duration, timing,
and presumed etiology. The mood disturbance component of depres-
sive disorders is accompanied by somatic and cognitive changes that
significantly interfere with tasks of daily functioning. Major depressive
disorder is diagnosed with change in affect, cognition, and neurovegeta-
tive functions occurring during a discrete episode of 2 weeks or longer.
Dysthymia, in contrast, is an appropriate diagnosis for a more chronic
and persistent form of depressive disorder that has mood disturbance
with a duration of at least 2 years in adults and 1 year for children.

Although Bereavement is not included in the Depressive Disorders
Category, it is often necessary to distinguish it from Major Depressive
Disorder. It is helpful to remember that with bereavement, the pre-
dominant feelings are of loss and emptiness, whereas in Major Depres-
sive Disorder, depressed mood and inability to anticipate happiness or
pleasure are predominant. In addition, grief is often experienced in
waves, whereas depression is more likely persistent and not tied to any
specific thoughts or reminders.

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Within the depressive disorders category, two new diagnoses were
added to the DSM–5. One is the Disruptive Mood Dysregulation Dis-
order which is characterized by severe and recurrent temper outbursts
as well as chronic and severe irritability. The recurrent temper tantrums
must be inconsistent with the developmental level of the individual
and have a frequency of three or more times per week. The other, Pre-
menstrual Dysphoric Disorder, is characterized by mood disturbance
present in the week before menses that weaken or diminish the week
after menses.

Anxiety Disorders

This group of disorders is characterized by excessive fear, anxiety, and
related behavioral problems. The anxious person has an emotional
response to a real or perceived threat, either present or expected to
occur. Many of these disorders can overlap; however, they also can dif-
fer in the objects or situations that elicit fear, anxiety, avoidance behav-
ior, and associated cognitions. Anxiety disorders are different from
developmentally normative fears in that they are excessive or persist
beyond what is deemed appropriate and cause significant distress or
impairment in social, academic, occupational, or other functioning. The
patient may not recognize that the fear is disproportional to the stressor,
so it may be up to the clinician to decide if the patient’s fear is excessive
given the patient’s thoughts, behaviors, and cultural context.

A few disorders previously categorized under disorders of infancy
and childhood have been moved to the anxiety disorders classification
because it has been recognized that these disorders can occur across the
life span. For example, separation anxiety disorder includes excessive
fear related to separation from home or major attachment figures. The
patient may fear that his or her attachment figure will be harmed or
lost or that some event will occur with the patient (e.g., getting lost or
kidnapped) that will prevent contact with the attachment figure. Actual
or anticipated separation from the attachment figure may also lead to
somatic complaints, including headaches, stomachaches, and other physi-
cal symptoms. Separation anxiety disorder is the most prevalent anxiety
disorder in children under 12 years of age, with prevalence decreasing
with age. The onset of the disorder can occur in adulthood as long as the
fear is not transient.

Selective mutism is characterized by consistent failure to speak in
social situations during which one is expected to speak. The patient is
able to speak in other situations (i.e., the disturbance is not the result of
a communication disorder) and has sufficient knowledge of and com-

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85Psychopathology and Use of the Diagnostic and Statistical Manual

fort with the required spoken language. Selective mutism is often asso-
ciated with social anxiety disorder or other anxiety disorders.

Specific phobia consists of fear or anxiety related to or avoidance of
certain objects or situations. In children, this fear may manifest itself as
crying, tantrums, freezing, or clinging behaviors. The phobic stimulus
must consistently produce fear, anxiety, or avoidance; be persistent (i.e.,
occur for at least 6 months); and cause significant distress or impairment.
Possible phobic situations and objects vary and can include animals; the
natural environment (e.g., storms, heights, water); blood, injection, and
injury (e.g., needles, medical procedures); situational contexts (e.g.,
planes, elevators, enclosed spaces); and other stimuli (e.g., loud noises,
costumes, choking or vomiting). Many patients have multiple phobias.

Individuals with social anxiety disorder exhibit fear or anxiety in
one or more social situations varying from daily activities (e.g., con-
versing, meeting new people, eating or drinking in public) to particular
events (e.g., giving a speech). In children, this fear must interfere with
interactions with peer as well as with adults. The fear relates to the
patient’s thinking she or he will behave in a way that others will eval-
uate negatively, leading to humiliation, embarrassment, or rejection.
Because of this fear, patients …

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