Coverage. With close to 400 possible diagnoses,
DSM-IV-TRcannot be faulted for being too limited
in its coverage of possible diagnostic conditions. It is
likely that most conditions that bring individuals in for
psychiatric or psychological treatment could be classi-
fied within theDSM-IV-TRsystem. However, some
may feel thatDSM-IV-TRerrs in the opposite direc-
tion—that its scope is too broad. For example, a host of
childhood developmental disorders are included as
mental disorders. The child who is dyslexic, has speech
problems such as stuttering, or has great difficulties
with arithmetic is given aDSM-IV-TR diagnosis.
Many question the appropriateness or benefit of label-
ing these conditions as mental disorders.
Another example of the possible overinclusive-
ness of theDSM-IV-TRis the inclusion of“premen-
strual dysphoric disorder”as a proposed diagnostic
category. This diagnosis and its criteria appear in
the appendix containing diagnostic criteria provided
for further study. Many women objected strenuously
to this diagnosis when it was first proposed because
they argued that such a category could easily be used
to discriminate against women in many areas (e.g.,
employment). Controversial diagnoses like this cause
some to wonder whether the architects of theDSM
have gone too far.Additional Concerns. Although the previously
described difficulties are real and fairly obvious, a
number of indirect or subtle problems arise through
the acceptance and use of diagnostic classification
systems. For example, classifications tend to create
the impression that mental disorders exist per se.
Such terms asdisorder,symptom, condition, andsuffer-
ing fromsuggest that the patient is the victim of a
disease process. The language of the system can
eventually lead even astute observers toward a
view that interprets learned reactions or person–
environment encounters as disease processes.
In addition, if we are not careful, we may
come to feel that classifying people is more satisfying
than trying to relieve their problems. As we shall see
later, therapy can be an uncertain, time-consuming
process that is often fraught with failure. But pigeon-
holing can be immediately rewarding: It provides a
sense of closure to the classifier. Like solving cross-
word puzzles, it may relieve tension without having
any long-term positive social significance.
The system likewise caters to the public’s desire
to regard problems in living as medical problems
that can be dealt with simply and easily by a pill,
an injection, or a scalpel. Unfortunately, however,
learning to solve psychological problems is hard
work. The easier approach is to adopt a passive,
dependent posture in which the patient is relieved
of psychological pain by an omniscient doctor.
Although such a view may be serviceable in dealing
with strictly medical problems (but see Engel,
1977), it has dubious value at best in confronting
the psychosocial problems of living.
A final indirect problem is that diagnosis can be
harmful or even stigmatizing to the person who is
labeled. In our society, diagnosis may close doors
rather than open them for patients and ex-patients.T A B L E 5-7 DSM-IV-TRCultural Formulation
DSM-IV-TR(APA, 2000) suggests that a mental health
professional supplement traditionalDSM-IV-TRdiagnostic
formulations with a cultural formulation of presenting
symptoms of clients whose cultural background differs
from that of the treating mental health professional.
Information is obtained to address the following topics:
■ Cultural identity of the client: Note the client’s ethnic
or cultural reference groups as well as language
abilities and preferences.
■ Cultural explanations of the client’s problems: Note
how the identified cultural group might explain the
present symptoms and how these symptoms com-
pare to those experienced by those in the cultural
reference group.
■ Cultural factors related to the psychosocial environ-
ment: Note how the cultural reference group might
interpret the social stresses, as well as availability of
social supports and other resources that may aid
treatment.
■ Cultural influences on the relationship between the
client and the mental health professional: Indicate
differences in cultural and social status between the
client and mental health professional that might
influence diagnosis and treatment.
■ Overall cultural assessment for diagnosis and care:
Summarize how cultural factors and considerations
are likely to influence the assessment and treatment
of the client.
152 CHAPTER 5