Abnormal Psychology

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82 CHAPTER 3


for a diagnosis of schizophrenia as an example (see
Table 3.4); this disorder is discussed in more detail in
Chapter 12. The criticisms raised in this discussion apply
to most DSM-IV-TR disorders. Let’s examine those criti-
cisms in detail.

Determining Clinical Signifi cance
Consider symptoms A3 and A4 in Table 3.4: disorga-
nized speech and grossly disorganized behavior. DSM-IV-
TR instructs the clinician to determine what constitutes
clinically signifi cant disorganized speech or behavior. Part
of the problem is that this decision, to a certain extent, is
subjective. Similarly, in Criterion B, dysfunction must be
markedly below the person’s previous level of functioning.
But DSM-IV-TR does not specify what, exactly, markedly
means (Caplan, 1995; Frances, First, & Pincus, 1995).
Not all professionals would consider the same patient’s
dysfunction marked enough to qualify as a symptom of
schizophrenia. These problems are complicated further if
the clinician relies on the patient’s description of his or
her previous level of functioning; the patient’s view of the
past may be clouded by the present symptoms.
In a similar vein, consider the category of disorders
known as adjustment disorders (see Table 3.1): These
disorders are characterized by a response to an identifi -
able stressor that is in excess of what would normally
be expected. The clinician must determine whether an
individual’s response is excessive. However, different people have different coping
styles, and what seems to one clinician like an excessive response may be deemed
normal by another clinician.

Disorders as Categories, Not Continua
DSM-IV-TR is structured so that someone either has or does not have a given disor-
der. It’s analogous to the old adage about pregnancy: A woman can’t be a little bit
pregnant—she either is or isn’t pregnant. But critics argue that many disorders may
exist along continua (continuous gradations), meaning that patients can have differ-
ent degrees of a disorder (Kendell & Jablensky, 2003).
Some psychologists propose that when the fi fth edition of DSM is developed,
each disorder should be classifi ed on a continuum, where the number or severity
of symptoms indicates the degree of severity of the disorder (Malik & Beutler,
2002; Westen et al., 2002). Subsequent editions of DSM may include a way to
diagnose disorders along a continuum in addition to a version of the current cat-
egorical system (First, 2006). If disorders were specifi ed along a continuum, plan-
ning appropriate goals and treatments would be easier, and prognoses might be
more accurate.
Consider, for example, two young men who have had the diagnosis of schizo-
phrenia for 5 years. Aaron has been living with roommates and attending college
part-time; Max is living at home, continues to hallucinate and have delusions, and
cannot hold down a volunteer job. Over the holidays, both men’s symptoms got
worse and both were hospitalized briefl y. Since being discharged from the hospi-
tal, Aaron has only mild symptoms, but Max still can’t function independently
even though he no longer needs to be in the hospital. The categorical diagnosis
of schizophrenia lumps both of these patients together, but the intensity of their
symptoms suggests that clinicians should have different expectations, goals, treat-
ments, and prognoses for them. As shown in Figure 3.1, on a dimensional scale,
one of them is likely to be diagnosed with mild schizophrenia, whereas the other is
likely to be diagnosed with severe schizophrenia.

Table 3.4 • DSM-IV-TR Diagnostic Criteria for Schizophrenia
Ta
Ch
to
cism

De
Co
niz
TR
clin
of
sub
ma
Bu
me
No
dys
sch
the
her
pas

kn
dis
abl
be

A. Characteristic symptoms: Two (or more) of the following, with each being pres-
ent for a signifi cant portion of time during a 1-month period:

(1) delusions
(2) hallucinations
(3) disorganized speech (evidenced by sentences that make no sense because
words are scrambled and the thoughts appear disconnected).
(4) grossly disorganized behavior (including diffi culty with daily tasks such as
organizing a meal or maintaining proper hygiene).
Note: The fi rst four symptoms are often referred to as positive symptoms, because
they suggest the presence of an excess or distortion of normal functions.
(5) negative symptoms (which indicate an absence of normal functions), such as
a failure to express or respond to emotion; slow, empty replies to questions;
or an inability to initiate goal-directed behavior.
Note: Only one Criterion A symptom is required if delusions are bizarre or
hallucinations consist of a voice keeping up a running commentary on the person’s
behavior or thoughts, or two or more voices conversing with each other.

B. Social/occupational dysfunction: Since the disturbance began, one or more
major areas of functioning such as work, interpersonal relations, or self-care are
markedly below the level achieved before the disturbance appeared.

C. Duration: Continuous signs of the disturbance persist for at least 6 months,
with at least 1 month of symptoms that meet Criterion A.

Source: Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders,
Text Revision, Fourth Edition, (Copyright 2000) American Psychiatric Association.
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