characteristic features beyond the disorder’s symp-
toms (e.g., demographic features); (b)laboratory stud-
ies (including psychological tests) to identify
meaningful correlates of the diagnosis; (c)delimita-
tion from other disordersto ensure some degree of
homogeneity among diagnostic members; (d)
follow-up studiesto assess the test–retest reliability
of a diagnosis; and (e)family studiesto demonstrate
that the proposed disorder tends to run in families,
suggesting a hereditary component to the disorder.
This particular five-stage method for establishing
diagnostic validity remains quite influential even
today. In fact, most contemporary research in psy-
chopathology represents one or more of the valida-
tion stages outlined by Robins and Guze.
Bias. Ideally, a classification system will not be
biased with respect to how diagnoses are assigned
to individuals who have different backgrounds (e.g.,
different gender, race, or socioeconomic status).
The validity and utility of a classification system
would be called into question if the same cluster
of behaviors resulted in a diagnosis for one individ-
ual but not for another individual. The two areas of
potential bias that have received the most attention
are sex bias and racial bias.
Some critics have attacked theDSMsystem as a
male-centered device that overestimates pathology
in females (M. Kaplan, 1983); others deny this
charge (Kass, Spitzer, & Williams, 1983). Widiger
and Spitzer (1991) presented a useful conceptual
analysis of what constitutessex biasin a diagnostic
system. They argue that previous attempts to dem-
onstrate diagnostic sex bias have been both concep-
tually and methodologically flawed. Further, some
of the findings of earlier studies (e.g., Broverman,
Broverman, Clarkson, Rosenkrantz, & Vogel,
1970) have been misinterpreted and misunderstood
(see Widiger & Settle, 1987, for a demonstration of
the flaws in the Broverman et al. study).
Widiger and Spitzer note that differential sex
prevalence for a disorder does not in and of itself
demonstrate diagnostic sex bias because, for example,
it is conceivable that biological factors or cultural
factors may make it more likely that males (or
females) will exhibit the criteria for a certain
diagnosis. For example, antisocial personality disor-
der is diagnosed much more frequently in men than
in women, and conduct disorder in boys more than
girls, but this may be the result of biological differ-
ences (e.g., testosterone) or other factors that influ-
ence the two genders differentially (e.g., societal
expectations for aggressiveness in men). However,
Widiger and Spitzer did present evidence suggesting
that clinicians may be biased in the way theyapply
diagnoses to males versus females, even in cases
where the symptoms presented by each were exactly
the same! Although this suggests that there may be
some bias in the way clinicians interpret the diagnos-
tic criteria (i.e., clinicians may exhibit sex bias), it
does not indicate sex bias within the diagnostic cri-
teria. These results suggest the need for better train-
ing of diagnosticians rather than an overhaul of the
diagnostic criteria.
Concerning bias due to race or ethnicity, it is
important to recognize that one’s culture can affect
many factors related to the diagnosis and treatment
of mental illness (Alarcón, 2009). First, culture can
influence belief systems that may lead to the expe-
rience of stress and then to symptoms of mental
disorder. Examples of these“culture-bound syn-
dromes” are provided in the DSM-IV-TR and
include conditions such as koro, dhat, frigophobia,
and voodoo death. Culture can also influence how
members cope with stress, leading potentially to
maladaptive behavior. The content or characteris-
tics of symptoms of mental disorder may also vary
by culture. Finally, culture is likely to impact the
willingness to seek treatment as well as the availabil-
ity of services.
Therefore, it is important for clinicians to con-
sider cultural influences when diagnosing and treat-
ing individuals for mental illness. Toward this end,
DSM-IV-TRoutlines procedures for making a cul-
tural formulation of an individual’s problems that
includes data on the individual’s cultural identity,
the cultural explanation of the problems, cultural
factors related to the psychosocial environment,
cultural influences on the relationship between the
individual and mental health professionals, and an
overall cultural assessment for the diagnosis and
treatment of the individual (see Table 5-7).DIAGNOSIS AND CLASSIFICATION OF PSYCHOLOGICAL PROBLEMS 151