84 CHAPTER 3
least 6 months. Someone who had these symptoms for 5 months and 29 days would
not be diagnosed with the disorder, but if the symptoms persisted another day, he or
she would be so diagnosed.Some Sets of Criteria Are Too Restrictive
Each category of disorders in DSM-IV-TR includes a not otherwise specifi ed (NOS)
diagnosis (American Psychiatric Association, 2000)—a nonspecific diagnosis
to be used when a person’s symptoms do not meet all the necessary criteria for
the disorder that is the best fi t, but the individual is signifi cantly distressed and
impaired. For instance, someone who had some—but not enough—of the symp-
toms to meet the criteria for schizophrenia or another psychotic disorder would
be diagnosed as having psychotic disorder NOS; this would be the case, for
example, for someone with only negative symptoms of schizophrenia (Criterion A5
in Table 3.4).
With some disorders, though, the criteria are so restrictive that most of the
distressed and impaired patients with appropriate symptoms don’t meet all the rel-
evant criteria to be diagnosed with that disorder; this is true for people with eating
disorders (Sloan, Mizes, & Epstein, 2005): Most people with an eating disorder are
diagnosed with the more general (and less reliable) eating disorder NOS, rather than
withbulimia nervosa oranorexia nervosa, the two diagnoses in the eating disorders
category. The criteria for bulimia and anorexia are suffi ciently restrictive that most
people with eating-related problems who have signifi cant distress, dysfunction, or
risk of harm have symptoms that fall short of the criteria. Those diagnosed with
eating disorder NOS are a very heterogeneous group of people, who have varying
problems associated with food and eating.
When NOS diagnoses occur frequently for a particular category of disorders, as
is the case with eating disorders, the criteria for the disorders may not meaningfully
capture the important elements needed for diagnosis—and hence the set of criteria
should be reevaluated.Psychological Disorders are Created to Ensure Payment
With each edition of DSM, the number of disorders has increased, reaching almost
300 with DSM-IV. Does this mean that more types of mental disorders have been
discovered and classifi ed? Not necessarily. This increase may, in part, refl ect eco-
nomic pressures in the mental health care industry (Eriksen & Kress, 2005). Today,
in order for a mental health facility or provider to be paid or a patient to be reim-
bursed by health insurance companies, the patient must have symptoms that meet
a DSM-IV-TR diagnosis. Prior to DSM-III-R, this requirement for payment did not
generally exist. The more disorders that are included in a new edition of DSM,
then, the more likely it is that a patient’s treatment will be paid for or reimbursed
by health insurance companies. But this does not imply that all of the disorders are
valid from a scientifi c perspective.Medical Illnesses are Made into Psychological Disorders
The DSM is beginning to include medical disorders, which are not clearly psycho-
logicaldisorders (Eriksen & Kress, 2005). For example, breathing-related sleep
disorder, which is included in DSM-IV-TR, is caused in part by an obstruction
of the breathing passage, a medical condition. No research evidence or medical
discoveries warranted the addition of this sleep disorders to Axis I of the DSM.
Rather, the decision was made by a small number of psychiatrists on the
DSM committee in order to ensure that treatment of this sleep disorder by men-
tal health clinicians would be paid for by health insurance companies; treatment
by mental health clinicians for disorders that are not included in the DSM is less
likely be paid for by most health insurance plans (Houts, 2002).
However, the push to include medical conditions in DSM is not entirely based on
fi nancial considerations: Clinicians have found that treatments developed for some
psychological disorders can also be used to treat some medical disorders success-
fully (Deckersbach et al., 2006). For example, a number of psychological treatments