Abnormal Psychology

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.