Psychological testing

From Wikipedia, the free encyclopedia

 

Psychological testing
Medical diagnostics
ICD-10-PCS	GZ1
ICD-9-CM	94.02
MeSH	D011581

Psychological testing is the administration of psychological tests, which are designed to be "an objective and standardized measure of a sample of behavior". The term sample of behavior refers to an individual's performance on tasks that have usually been prescribed beforehand. The samples of behavior that make up a paper-and-pencil test, the most common type of test, are a series of items. Performance on these items produce a test score. A score on a well-constructed test is believed to reflect a psychological construct such as achievement in a school subject, cognitive ability, aptitude, emotional functioning, personality, etc. Differences in test scores are thought to reflect individual differences in the construct the test is supposed to measure. The science behind psychological testing is psychometrics.

Psychological tests

A psychological test is an instrument designed to measure unobserved constructs, also known as latent variables. Psychological tests are typically, but not necessarily, a series of tasks or problems that the respondent has to solve. Psychological tests can strongly resemble questionnaires, which are also designed to measure unobserved constructs, but differ in that psychological tests ask for a respondent's maximum performance whereas a questionnaire asks for the respondent's typical performance. A useful psychological test must be both valid (i.e., there is evidence to support the specified interpretation of the test results) and reliable (i.e., internally consistent or give consistent results over time, across raters, etc.). 

It is important that people who are equal on the measured construct also have an equal probability of answering the test items accurately. For example, an item on a mathematics test could be "In a soccer match two players get a red card; how many players are left in the end?"; however, this item also requires knowledge of soccer to be answered correctly, not just mathematical ability. Group membership can also influence the chance of correctly answering items (differential item functioning). Often tests are constructed for a specific population, and this should be taken into account when administering tests. If a test is invariant to some group difference (e.g. gender) in one population (e.g. England) it does not automatically mean that it is also invariant in another population (e.g. Japan). 

Psychological assessment is similar to psychological testing but usually involves a more comprehensive assessment of the individual. Psychological assessment is a process that involves checking the integration of information from multiple sources, such as tests of normal and abnormal personality, tests of ability or intelligence, tests of interests or attitudes, as well as information from personal interviews. Collateral information is also collected about personal, occupational, or medical history, such as from records or from interviews with parents, spouses, teachers, or previous therapists or physicians. A psychological test is one of the sources of data used within the process of assessment; usually more than one test is used. Many psychologists do some level of assessment when providing services to clients or patients, and may use for example, simple checklists to osis for treatment settings; to assess a particular area of functioning or disability often for school settings; to help select type of treatment or to assess treatment outcomes; to help courts decide issues such as child custody or competency to stand trial; or to help assess job applicants or employees and provide career development counseling or training.

History

A Song Dynasty painting of candidates participating in the imperial examination, a rudimentary form of psychological testing.

 

Physiognomy was used to assess personality traits based on an individual's outer appearance.

 

The first large-scale tests may have been examinations that were part of the imperial examination system in China. The test, an early form of psychological testing, assessed candidates based on their proficiency in topics such as civil law and fiscal policies. Other early tests of intelligence were made for entertainment rather than analysis. Modern mental testing began in France in the 19th century. It contributed to separating mental retardation from mental illness and reducing the neglect, torture, and ridicule heaped on both groups.

Englishman Francis Galton coined the terms psychometrics and eugenics, and developed a method for measuring intelligence based on nonverbal sensory-motor tests. It was initially popular, but was abandoned after the discovery that it had no relationship to outcomes such as college grades. French psychologist Alfred Binet, together with psychologists Victor Henri and Théodore Simon, after about 15 years of development, published the Binet-Simon test in 1905, which focused on verbal abilities. It was intended to identify mental retardation in school children.

The origins of personality testing date back to the 18th and 19th centuries, when personality was assessed through phrenology, the measurement of the human skull, and physiognomy, which assessed personality based on a person's outer appearances. These early pseudoscientific techniques were eventually replaced with more empirical methods in the 20th century. One of the earliest modern personality tests was the Woolworth Personality Data Sheet, a self-report inventory developed for World War I and used for the psychiatric screening of new draftees.

Principles

Proper psychological testing is conducted after vigorous research and development in contrast to quick web-based or magazine questionnaires that say "Find out your Personality Color," or "What's your Inner Age?" Proper psychological testing consists of the following:

• Standardization - All procedures and steps must be conducted with consistency and under the same environment to achieve the same testing performance from those being tested.
• Objectivity - Scoring such that subjective judgments and biases are minimized, with results for each test taker obtained in the same way.
• Test Norms - The average test score within a large group of people where the performance of one individual can be compared to the results of others by establishing a point of comparison or frame of reference.
• Reliability - Obtaining the same result after multiple testing.
• Validity - The type of test being administered must measure what it is intended to measure.

Interpreting scores

Psychological tests, like many measurements of human characteristics, can be interpreted in a norm-referenced or criterion-referenced manner. Norms are statistical representations of a population. A norm-referenced score interpretation compares an individual's results on the test with the statistical representation of the population. In practice, rather than testing a population, a representative sample or group is tested. This provides a group norm or set of norms. One representation of norms is the Bell curve (also called "normal curve"). Norms are available for standardized psychological tests, allowing for an understanding of how an individual's scores compare with the group norms. Norm referenced scores are typically reported on the standard score (z) scale or a rescaling of it. 

A criterion-referenced interpretation of a test score compares an individual's performance to some criterion other than performance of other individuals. For example, the generic school test typically provides a score in reference to a subject domain; a student might score 80% on a geography test. Criterion-referenced score interpretations are generally more applicable to achievement tests rather than psychological tests. 

Often, test scores can be interpreted in both ways; answering 80% of the questions correctly on a geography test could place a student at the 84th percentile (that is, the student performed better than 83% of the class and worse than 16% of the classmates), or a standard score of 1.0 or even 2.0.

Types

There are several broad categories of psychological tests:

IQ/achievement tests

IQ tests purport to be measures of intelligence, while achievement tests are measures of the use and level of development of use of the ability. IQ (or cognitive) tests and achievement tests are common norm-referenced tests. In these types of tests, a series of tasks is presented to the person being evaluated, and the person's responses are graded according to carefully prescribed guidelines. After the test is completed, the results can be compiled and compared to the responses of a norm group, usually composed of people at the same age or grade level as the person being evaluated. IQ tests which contain a series of tasks typically divide the tasks into verbal (relying on the use of language) and performance, or non-verbal (relying on eye–hand types of tasks, or use of symbols or objects). Examples of verbal IQ test tasks are vocabulary and information (answering general knowledge questions). Non-verbal examples are timed completion of puzzles (object assembly) and identifying images which fit a pattern (matrix reasoning). 

IQ tests (e.g., WAIS-IV, WISC-V, Cattell Culture Fair III, Woodcock-Johnson Tests of Cognitive Abilities-IV, Stanford-Binet Intelligence Scales V) and academic achievement tests (e.g. WIAT, WRAT, Woodcock-Johnson Tests of Achievement-III) are designed to be administered to either an individual (by a trained evaluator) or to a group of people (paper and pencil tests). The individually administered tests tend to be more comprehensive, more reliable, more valid and generally to have better psychometric characteristics than group-administered tests. However, individually administered tests are more expensive to administer because of the need for a trained administrator (psychologist, school psychologist, or psychometrician).

Public safety employment tests

Vocations within the public safety field (i.e., fire service, law enforcement, corrections, emergency medical services) often require Industrial and Organizational Psychology tests for initial employment and advancement throughout the ranks. The National Firefighter Selection Inventory - NFSI, the National Criminal Justice Officer Selection Inventory - NCJOSI, and the Integrity Inventory are prominent examples of these tests.

Attitude tests

Attitude test assess an individual's feelings about an event, person, or object. Attitude scales are used in marketing to determine individual (and group) preferences for brands, or items. Typically attitude tests use either a Thurstone scale, or Likert Scale to measure specific items.

Neuropsychological tests

These tests consist of specifically designed tasks used to measure a psychological function known to be linked to a particular brain structure or pathway. Neuropsychological tests can be used in a clinical context to assess impairment after an injury or illness known to affect neurocognitive functioning. When used in research, these tests can be used to contrast neuropsychological abilities across experimental groups. 

Infant and Preschool Assessment

Due to the fact that infants and preschool aged children have limited capacities of communication, psychologists are unable to use traditional tests to assess them. Therefore, many tests have been designed just for children ages birth to around six years of age. These tests usually vary with age respectively from assessments of reflexes and developmental milestones, to sensory and motor skills, language skills, and simple cognitive skills.

Common tests for this age group are split into categories: Infant Ability, Preschool Intelligence, and School Readiness. Common infant ability tests include: Gesell Developmental Schedules (GDS) which measures the developmental progress of infants, Neonatal Behavioral Assessment Scale (NBAS) which tests newborn behavior, reflexes, and responses, Ordinal Scales of Psychological Development (OSPD) which assesses infant intellectual abilities, and Bayley-III which tests mental ability and motor skills.

Common preschool intelligence tests include: McCarthy Scales of Children’s Abilities (MSCA) which is similar to an infant IQ test, Differential Ability Scales (DAS) which can be used to test for learning disability, Wechsler Preschool and Primary Scale of Intelligence-III (WPPSI-III) and Stanford-Binet Intelligence Scales for Early Childhood which could be seen as infant versions of IQ tests, and Fagan Test of Infant Intelligence (FTII) which tests recognition memory.

Finally, some common school readiness tests are: Developmental Indicators for the Assessment of Learning-III (DIAL-III) which assesses motor, cognitive, and language skills, Denver II which tests motor, social, and language skills, and Home Observation for Measurement of Environment (HOME) which is a measure of the extent to which a child’s home environment facilitates school readiness.

Infant and preschool assessments, since they do not predict later childhood nor adult abilities, are mainly useful for testing if a child is experiencing developmental delay or disabilities. They are also useful for testing individual intelligence and ability, and, as aforementioned, there are some specifically designed to test school readiness and determine which children may struggle more in school.

Personality tests

Psychological measures of personality are often described as either objective tests or projective tests. The terms "objective test" and "projective test" have recently come under criticism in the Journal of Personality Assessment. The more descriptive "rating scale or self-report measures" and "free response measures" are suggested, rather than the terms "objective tests" and "projective tests," respectively.

Objective tests (Rating scale or self-report measure)

Objective tests have a restricted response format, such as allowing for true or false answers or rating using an ordinal scale. Prominent examples of objective personality tests include the Minnesota Multiphasic Personality Inventory, Millon Clinical Multiaxial Inventory-IV, Child Behavior Checklist, Symptom Checklist 90 and the Beck Depression Inventory. Objective personality tests can be designed for use in business for potential employees, such as the NEO-PI, the 16PF, and the OPQ (Occupational Personality Questionnaire), all of which are based on the Big Five taxonomy. The Big Five, or Five Factor Model of normal personality, has gained acceptance since the early 1990s when some influential meta-analyses (e.g., Barrick & Mount 1991) found consistent relationships between the Big Five personality factors and important criterion variables. 

Another personality test based upon the Five Factor Model is the Five Factor Personality Inventory – Children (FFPI-C.).

Projective tests (Free response measures)

Projective tests allow for a freer type of response. An example of this would be the Rorschach test, in which a person states what each of ten ink blots might be.

Projective testing became a growth industry in the first half of the 1900s, with doubts about the theoretical assumptions behind projective testing arising in the second half of the 1900s. Some projective tests are used less often today because they are more time consuming to administer and because the reliability and validity are controversial.

As improved sampling and statistical methods developed, much controversy regarding the utility and validity of projective testing has occurred. The use of clinical judgement rather than norms and statistics to evaluate people's characteristics has raised criticism that projectives are deficient and unreliable (results are too dissimilar each time a test is given to the same person). However, as more objective scoring and interpretive systems supported by more rigorous scientific research have emerged, many practitioners continue to rely on projective testing. Projective tests may be useful in creating inferences to follow up with other methods. The most widely used scoring system for the Rorschach is the Exner system of scoring. Another common projective test is the Thematic Apperception Test (TAT), which is often scored with Westen's Social Cognition and Object Relations Scales and Phebe Cramer's Defense Mechanisms Manual. Both "rating scale" and "free response" measures are used in contemporary clinical practice, with a trend toward the former.

Other projective tests include the House-Tree-Person test, the Animal Metaphor Test.

Sexological tests

The number of tests specifically meant for the field of sexology is quite limited. The field of sexology provides different psychological evaluation devices in order to examine the various aspects of the discomfort, problem or dysfunction, regardless of whether they are individual or relational ones.

Direct observation tests

Although most psychological tests are "rating scale" or "free response" measures, psychological assessment may also involve the observation of people as they complete activities. This type of assessment is usually conducted with families in a laboratory, home or with children in a classroom. The purpose may be clinical, such as to establish a pre-intervention baseline of a child's hyperactive or aggressive classroom behaviors or to observe the nature of a parent-child interaction in order to understand a relational disorder. Direct observation procedures are also used in research, for example to study the relationship between intrapsychic variables and specific target behaviors, or to explore sequences of behavioral interaction. 

The Parent-Child Interaction Assessment-II (PCIA) is an example of a direct observation procedure that is used with school-age children and parents. The parents and children are video recorded playing at a make-believe zoo. The Parent-Child Early Relational Assessment is used to study parents and young children and involves a feeding and a puzzle task. The MacArthur Story Stem Battery (MSSB) is used to elicit narratives from children. The Dyadic Parent-Child Interaction Coding System-II tracks the extent to which children follow the commands of parents and vice versa and is well suited to the study of children with Oppositional Defiant Disorders and their parents.

Interest tests

Psychological tests to assess a person’s interests and preferences. These tests are used primarily for career counseling. Interest tests include items about daily activities from among which applicants select their preferences. The rationale is that if a person exhibits the same pattern of interests and preferences as people who are successful in a given occupation, then the chances are high that the person taking the test will find satisfaction in that occupation. A widely used interest test is the Strong Interest Inventory, which is used in career assessment, career counseling, and educational guidance.

Aptitude tests

Psychological tests measure specific abilities, such as clerical, perceptual, numerical, or spatial aptitude. Sometimes these tests must be specially designed for a particular job, but there are also tests available that measure general clerical and mechanical aptitudes, or even general learning ability. An example of an occupational aptitude test is the Minnesota Clerical Test, which measures the perceptual speed and accuracy required to perform various clerical duties. Other widely used aptitude tests include Careerscope, the Differential Aptitude Tests (DAT), which assess verbal reasoning, numerical ability, abstract Reasoning, clerical speed and accuracy, mechanical reasoning, space relations, spelling and language usage. Another widely used test of aptitudes is the Wonderlic Test. These aptitudes are believed to be related to specific occupations and are used for career guidance as well as selection and recruitment.

Biographical Information Blank

The Biographical Information Blanks or BIB is a paper-and-pencil form that includes items that ask about detailed personal and work history. It is used to aid in the hiring of employees by matching the backgrounds of individuals to requirements of the job.

Test security

Many psychological tests are generally not available to the public, but rather, have restrictions both from publishers of the tests and from psychology licensing boards that prevent the disclosure of the tests themselves and information about the interpretation of the results. Test publishers consider both copyright and matters of professional ethics to be involved in protecting the secrecy of their tests, and they sell tests only to people who have proved their educational and professional qualifications to the test maker's satisfaction. Purchasers are legally bound from giving test answers or the tests themselves out to the public unless permitted under the test maker's standard conditions for administration of the tests.

The International Test Commission (ITC), an international association of national psychological societies and test publishers, publishes the International Guidelines for Test Use, which prescribes to "protect the integrity" of the tests by not publicly describing test techniques and by not "coaching individuals" so that they "might unfairly influence their test performance."

Hypochondriasis

From Wikipedia, the free encyclopedia

Hypochondriasis
Other names	Hypochondria, health anxiety (HA), illness anxiety disorder, somatic symptom disorder
Specialty	Psychiatry, psychology
Treatment	Cognitive behavioral therapy
Medication	SSRI, antidepressants
Frequency	~5%

Hypochondriasis or hypochondria is a condition in which a person is excessively and unduly worried about having a serious illness. An old concept, its meaning has repeatedly changed due to redefinitions in its source metaphors. It has been claimed that this debilitating condition results from an inaccurate perception of the condition of body or mind despite the absence of an actual medical diagnosis. An individual with hypochondriasis is known as a hypochondriac. Hypochondriacs become unduly alarmed about any physical or psychological symptoms they detect, no matter how minor the symptom may be, and are convinced that they or others have, or are about to be diagnosed with, a serious illness.

Often, hypochondria persists even after a physician has evaluated a person and reassured them that their concerns about symptoms do not have an underlying medical basis or, if there is a medical illness, their concerns are far in excess of what is appropriate for the level of disease. Many hypochondriacs focus on a particular symptom as the catalyst of their worrying, such as gastro-intestinal problems, palpitations, or muscle fatigue. To qualify for the diagnosis of hypochondria the symptoms must have been experienced for at least 6 months.

The DSM-IV-TR defines this disorder, "Hypochondriasis", as a somatoform disorder and one study has shown it to affect about 3% of the visitors to primary care settings. The 2013 DSM-5 replaced the diagnosis of hypochondriasis with the diagnoses of "somatic symptom disorder" and "illness anxiety disorder".

Hypochondria is often characterized by fears that minor bodily or mental symptoms may indicate a serious illness, constant self-examination and self-diagnosis, and a preoccupation with one's body. Many individuals with hypochondriasis express doubt and disbelief in the doctors' diagnosis, and report that doctors’ reassurance about an absence of a serious medical condition is unconvincing, or short-lasting. Additionally, many hypochondriacs experience elevated blood pressure, stress, and anxiety in the presence of doctors or while occupying a medical facility, a condition known as "white coat syndrome". Many hypochondriacs require constant reassurance, either from doctors, family, or friends, and the disorder can become a debilitating challenge for the individual with hypochondriasis, as well as their family and friends.^[8] Some hypochondriacal individuals completely avoid any reminder of illness, whereas others frequently visit medical facilities, sometimes obsessively. Some sufferers may never speak about it.

Signs and symptoms

Hypochondriasis is categorized as a somatic amplification disorder—a disorder of "perception and cognition"—that involves a hyper-vigilance of situation of the body or mind and a tendency to react to the initial perceptions in a negative manner that is further debilitating. Hypochondriasis manifests in many ways. Some people have numerous intrusive thoughts and physical sensations that push them to check with family, friends, and physicians. For example, a person who has a minor cough may think that they have tuberculosis. Or sounds produced by organs in the body, such as those made by the intestines, might be seen as a sign of a very serious illness to patients dealing with hypochondriasis.

Other people are so afraid of any reminder of illness that they will avoid medical professionals for a seemingly minor problem, sometimes to the point of becoming neglectful of their health when a serious condition may exist and go undiagnosed. Yet others live in despair and depression, certain that they have a life-threatening disease and no physician can help them. Some consider the disease as a punishment for past misdeeds.

Hypochondriasis is often accompanied by other psychological disorders. Bipolar disorder, clinical depression, obsessive-compulsive disorder (OCD), phobias, and somatization disorder are the most common accompanying conditions in people with hypochondriasis, as well as a generalized anxiety disorder diagnosis at some point in their life.

Many people with hypochondriasis experience a cycle of intrusive thoughts followed by compulsive checking, which is very similar to the symptoms of obsessive-compulsive disorder. However, while people with hypochondriasis are afraid of having an illness, patients with OCD worry about getting an illness or of transmitting an illness to others. Although some people might have both, these are distinct conditions.

Patients with hypochondriasis often are not aware that depression and anxiety produce their own physical symptoms, and mistake these symptoms for manifestations of another mental or physical disorder or disease. For example, people with depression often experience changes in appetite and weight fluctuation, fatigue, decreased interest in sex and motivation in life overall. Intense anxiety is associated with rapid heartbeat, palpitations, sweating, muscle tension, stomach discomfort, dizziness, and numbness or tingling in certain parts of the body (hands, forehead, etc.).

If a person is ill with a medical disease such as diabetes or arthritis, there will often be psychological consequences, such as depression. Some even report being suicidal. In the same way, someone with psychological issues such as depression or anxiety will sometimes experience physical manifestations of these affective fluctuations, often in the form of medically unexplained symptoms. Common symptoms include headaches; abdominal, back, joint, rectal, or urinary pain; nausea; fever and/or night sweats; itching; diarrhea; dizziness; or balance problems. Many people with hypochondriasis accompanied by medically unexplained symptoms feel they are not understood by their physicians, and are frustrated by their doctors’ repeated failure to provide symptom relief.

Diagnosis

The ICD-10 defines hypochondriasis as follows:

A. Either one of the following:

• A persistent belief, of at least six months' duration, of the presence of a minimum of two serious physical diseases (of which at least one must be specifically named by the patient).
• A persistent preoccupation with a presumed deformity or disfigurement (body dysmorphic disorder).

B. Preoccupation with the belief and the symptoms causes persistent distress or interference with personal functioning in daily living, and leads the patient to seek medical treatment or investigations (or equivalent help from local healers).

C. Persistent refusal to accept medical advice that there is no adequate physical cause for the symptoms or physical abnormality, except for short periods of up to a few weeks at a time immediately after or during medical investigations.

D. Most commonly used exclusion criteria: not occurring only during any of the schizophrenia and related disorders (F20–F29, particularly F22) or any of the mood disorders (F30–F39).

The DSM-IV defines hypochondriasis according to the following criteria:

A. Preoccupation with fears of having, or the idea that one has, a serious disease based on the person's misinterpretation of bodily symptoms.
B. The preoccupation persists despite appropriate medical evaluation and reassurance.
C. The belief in Criterion A is not of delusional intensity (as in Delusional Disorder, Somatic Type) and is not restricted to a circumscribed concern about appearance (as in Body Dysmorphic Disorder).
D. The preoccupation causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.
E. The duration of the disturbance is at least 6 months.
F. The preoccupation is not better accounted for by Generalized Anxiety Disorder, Obsessive-Compulsive Disorder, Panic Disorder, a Major Depressive Episode, Separation Anxiety, or another Somatoform Disorder.

The newly published DSM-5 replaces the diagnosis of hypochondriasis with "illness anxiety disorder".

Cause

Hypochondria is currently considered a psychosomatic disorder, as in a mental illness with physical symptoms. Cyberchondria is a colloquial term for hypochondria in individuals who have researched medical conditions on the Internet. The media and the Internet often contribute to hypochondria, as articles, TV shows and advertisements regarding serious illnesses such as cancer and multiple sclerosis often portray these diseases as being random, obscure and somewhat inevitable. Inaccurate portrayal of risk and the identification of non-specific symptoms as signs of serious illness contribute to exacerbating the hypochondriac’s fear that they actually have that illness.

Major disease outbreaks or predicted pandemics can also contribute to hypochondria. Statistics regarding certain illnesses, such as cancer, will give hypochondriacs the illusion that they are more likely to develop the disease.

Overly protective caregivers and an excessive focus on minor health concerns have been implicated as a potential cause of hypochondriasis development.

It is common for serious illnesses or deaths of family members or friends to trigger hypochondria in certain individuals. Similarly, when approaching the age of a parent's premature death from disease, many otherwise healthy, happy individuals fall prey to hypochondria. These individuals believe they are suffering from the same disease that caused their parent's death, sometimes causing panic attacks with corresponding symptoms.

Family studies of hypochondriasis do not show a genetic transmission of the disorder. Among relatives of people suffering from hypochondriasis only somatization disorder and generalized anxiety disorder were more common than in average families. Other studies have shown that the first degree relatives of patients with OCD have a higher than expected frequency of a somatoform disorder (either hypochondriasis or body dysmorphic disorder).

Treatment

Most research indicates that cognitive behavioral therapy (CBT) is an effective treatment for hypochondriasis. Much of this research is limited by methodological issues. A small amount of evidence suggests that selective serotonin reuptake inhibitors can also reduce symptoms, but further research is needed. In some cases, hypochondriasis responds well to antipsychotics, particularly the newer atypical antipsychotic medications.

Etymology

Among the regions of the abdomen, the hypochondrium is the uppermost part. The word derives from the Greek term ὑποχόνδριος hypokhondrios, meaning "of the soft parts between the ribs and navel" from ὑπό hypo ("under") and χόνδρος khondros, or cartilage (of the sternum). Hypochondria in Late Latin meant "the abdomen".

The term hypochondriasis for a state of disease without real cause reflected the ancient belief that the viscera of the hypochondria were the seat of melancholy and sources of the vapor that caused morbid feelings. Until the early 18th century, the term referred to a "physical disease caused by imbalances in the region that was below your rib cage" (i.e., of the stomach or digestive system). For example, Robert Burton's The Anatomy of Melancholy (1621) blamed it "for everything from 'too much spittle' to 'rumbling in the guts'".

Immanuel Kant discussed hypochondria in his 1798 book, Anthropology like this:

The disease of the hypochondriac consists in this: that certain bodily sensations do not so much indicate a really existing disease in the body as rather merely excite apprehensions of its existence: and human nature is so constituted – a trait which the animal lacks – that it is able to strengthen or make permanent local impressions simply by paying attention to them, whereas an abstraction – whether produced on purpose or by other diverting occupations – lessen these impressions, or even effaces them altogether.

• Anthropology by Immanuel Kant, 1798 Journal of Speculative Philosophy Vol. XVI edited by William Torrey Harris p. 395-396

Classification of mental disorders

From Wikipedia, the free encyclopedia

 

The classification of mental disorders is also known as psychiatric nosology or psychiatric taxonomy. It represents a key aspect of psychiatry and other mental health professions and is an important issue for people who may be diagnosed. There are currently two widely established systems for classifying mental disorders:

• Chapter V of the International Classification of Diseases (ICD-10) produced by the World Health Organization (WHO)
• The Diagnostic and Statistical Manual of Mental Disorders (DSM-5) produced by the American Psychiatric Association (APA).

Both list categories of disorders thought to be distinct types, and have deliberately converged their codes in recent revisions so that the manuals are often broadly comparable, although significant differences remain. Other classification schemes may be in use more locally, for example the Chinese Classification of Mental Disorders. Other manuals have some limited use by those of alternative theoretical persuasions, such as the Psychodynamic Diagnostic Manual.

The widely used DSM and ICD classifications employ operational definitions. There is a significant scientific debate about the relative validity of a "categorical" versus a "dimensional" approach to classification, as well as significant controversy about the role of science and values in classification schemes and the professional, legal and social uses to which they are put.

Definitions

In the scientific and academic literature on the definition or categorization of mental disorders, one extreme argues that it is entirely a matter of value judgments (including of what is normal) while another proposes that it is or could be entirely objective and scientific (including by reference to statistical norms); other views argue that the concept refers to a "fuzzy prototype" that can never be precisely defined, or that the definition will always involve a mixture of scientific facts (e.g. that a natural or evolved function isn't working properly) and value judgments (e.g. that it is harmful or undesired). Lay concepts of mental disorder vary considerably across different cultures and countries, and may refer to different sorts of individual and social problems.

The WHO and national surveys report that there is no single consensus on the definition of mental disorder, and that the phrasing used depends on the social, cultural, economic and legal context in different contexts and in different societies. The WHO reports that there is intense debate about which conditions should be included under the concept of mental disorder; a broad definition can cover mental illness, mental retardation, personality disorder and substance dependence, but inclusion varies by country and is reported to be a complex and debated issue. There may be a criterion that a condition should not be expected to occur as part of a person's usual culture or religion. However, despite the term "mental", there is not necessarily a clear distinction drawn between mental (dys)functioning and brain (dys)functioning, or indeed between the brain and the rest of the body.

Most international clinical documents avoid the term "mental illness", preferring the term "mental disorder". However, some use "mental illness" as the main overarching term to encompass mental disorders. Some consumer/survivor movement organizations oppose use of the term "mental illness" on the grounds that it supports the dominance of a medical model. The term "serious mental impairment" (SMI) is sometimes used to refer to more severe and long-lasting disorders while "mental health problems" may be used as a broader term, or to refer only to milder or more transient issues. Confusion often surrounds the ways and contexts in which these terms are used.

Mental disorders are generally classified separately to neurological disorders, learning disabilities or mental retardation.

ICD-10

The International Classification of Diseases (ICD) is an international standard diagnostic classification for a wide variety of health conditions. The ICD-10 states that mental disorder is "not an exact term", although is generally used "...to imply the existence of a clinically recognisable set of symptoms or behaviours associated in most cases with distress and with interference with personal functions." Chapter V focuses on "mental and behavioural disorders" and consists of 10 main groups:

• F0: Organic, including symptomatic, mental disorders
• F1: Mental and behavioural disorders due to use of psychoactive substances
• F2: Schizophrenia, schizotypal and delusional disorders
• F3: Mood [affective] disorders
• F4: Neurotic, stress-related and somatoform disorders
• F5: Behavioural syndromes associated with physiological disturbances and physical factors
• F6: Disorders of personality and behaviour in adult persons
• F7: Mental retardation
• F8: Disorders of psychological development
• F9: Behavioural and emotional disorders with onset usually occurring in childhood and adolescence
• In addition, a group of "unspecified mental disorders".

Within each group there are more specific subcategories. The WHO is revising their classifications in this section as part of the development of the ICD-11 (revision due by 2018) and an "International Advisory Group" has been established to guide this.

DSM-IV

The DSM-IV was originally published in 1994 and listed more than 250 mental disorders. It was produced by the American Psychiatric Association and it characterizes mental disorder as "a clinically significant behavioral or psychological syndrome or pattern that occurs in an individual,...is associated with present distress...or disability...or with a significant increased risk of suffering" but that "...no definition adequately specifies precise boundaries for the concept of 'mental disorder'...different situations call for different definitions" (APA, 1994 and 2000). The DSM also states that "there is no assumption that each category of mental disorder is a completely discrete entity with absolute boundaries dividing it from other mental disorders or from no mental disorders." 

The DSM-IV-TR (Text Revision, 2000) consisted of five axes (domains) on which disorder could be assessed. The five axes were:

Axis I: Clinical Disorders (all mental disorders except Personality Disorders and Mental Retardation)

Axis II: Personality Disorders and Mental Retardation

Axis III: General Medical Conditions (must be connected to a Mental Disorder)

Axis IV: Psychosocial and Environmental Problems (for example limited social support network)

Axis V: Global Assessment of Functioning (Psychological, social and job-related functions are evaluated on a continuum between mental health and extreme mental disorder)

The axis classification system was removed in the DSM-5 and is now mostly of historical significance. The main categories of disorder in the DSM are:

DSM Group	Examples
Disorders usually first diagnosed in infancy, childhood or adolescence. *Disorders such as ADHD and epilepsy have also been referred to as developmental disorders and developmental disabilities.	ADHD
Delirium, dementia, and amnesia and other cognitive disorders	Alzheimer's disease
Mental disorders due to a general medical condition	AIDS-related psychosis
Substance-related disorders	Alcohol abuse
Schizophrenia and other psychotic disorders	Delusional disorder
Mood disorders	Major depressive disorder, Bipolar disorder
Anxiety disorders	Generalized anxiety disorder, Social anxiety disorder
Somatoform disorders	Somatization disorder
Factitious disorders	Münchausen syndrome
Dissociative disorders	Dissociative identity disorder
Sexual and gender identity disorders	Dyspareunia, Gender identity disorder
Eating disorders	Anorexia nervosa, Bulimia nervosa
Sleep disorders	Insomnia
Impulse control disorders not elsewhere classified	Kleptomania
Adjustment disorders	Adjustment disorder
Personality disorders	Narcissistic personality disorder
Other conditions that may be a focus of clinical attention	Tardive dyskinesia, Child abuse

Other schemes

• The Chinese Society of Psychiatry's Chinese Classification of Mental Disorders (currently CCMD-3)
• The Latin American Guide for Psychiatric Diagnosist (GLDP).
• The Research Domain Criteria (RDoC), a framework being developed by the National Institute of Mental Health

Childhood diagnosis

Child and adolescent psychiatry sometimes uses specific manuals in addition to the DSM and ICD. The Diagnostic Classification of Mental Health and Developmental Disorders of Infancy and Early Childhood (DC:0-3) was first published in 1994 by Zero to Three to classify mental health and developmental disorders in the first four years of life. It has been published in 9 languages. The Research Diagnostic criteria-Preschool Age (RDC-PA) was developed between 2000 and 2002 by a task force of independent investigators with the goal of developing clearly specified diagnostic criteria to facilitate research on psychopathology in this age group. The French Classification of Child and Adolescent Mental Disorders (CFTMEA), operational since 1983, is the classification of reference for French child psychiatrists.

Usage

The ICD and DSM classification schemes have achieved widespread acceptance in psychiatry. A survey of 205 psychiatrists, from 66 different countries across all continents, found that ICD-10 was more frequently used and more valued in clinical practice and training, while the DSM-IV was more frequently used in clinical practice in the United States and Canada, and was more valued for research, with accessibility to either being limited, and usage by other mental health professionals, policy makers, patients and families less clear. . A primary care (e.g. general or family physician) version of the mental disorder section of ICD-10 has been developed (ICD-10-PHC) which has also been used quite extensively internationally. A survey of journal articles indexed in various biomedical databases between 1980 and 2005 indicated that 15,743 referred to the DSM and 3,106 to the ICD.

In Japan, most university hospitals use either the ICD or DSM. ICD appears to be the somewhat more used for research or academic purposes, while both were used equally for clinical purposes. Other traditional psychiatric schemes may also be used.

Types of classification schemes

Categorical schemes

The classification schemes in common usage are based on separate (but may be overlapping) categories of disorder schemes sometimes termed "neo-Kraepelinian" (after the psychiatrist Kraepelin) which is intended to be atheoretical with regard to etiology (causation). These classification schemes have achieved some widespread acceptance in psychiatry and other fields, and have generally been found to have improved inter-rater reliability, although routine clinical usage is less clear. Questions of validity and utility have been raised, both scientifically and in terms of social, economic and political factors—notably over the inclusion of certain controversial categories, the influence of the pharmaceutical industry, or the stigmatizing effect of being categorized or labelled.

Non-categorical schemes

Some approaches to classification do not use categories with single cut-offs separating the ill from the healthy or the abnormal from the normal (a practice sometimes termed "threshold psychiatry" or "dichotomous classification").

Classification may instead be based on broader underlying "spectra", where each spectrum links together a range of related categorical diagnoses and nonthreshold symptom patterns.

Some approaches go further and propose continuously-varying dimensions that are not grouped into spectra or categories; each individual simply has a profile of scores across different dimensions. DSM-5 planning committees are currently seeking to establish a research basis for a hybrid dimensional classification of personality disorders. However, the problem with entirely dimensional classifications is they are said to be of limited practical value in clinical practice where yes/no decisions often need to be made, for example whether a person requires treatment, and moreover the rest of medicine is firmly committed to categories, which are assumed to reflect discrete disease entities. While the Psychodynamic Diagnostic Manual has an emphasis on dimensionality and the context of mental problems, it has been structured largely as an adjunct to the categories of the DSM. Moreover, dimensionality approach was criticized for its reliance on independent dimensions whereas all systems of behavioral regulations show strong inter-dependence, feedback and contingent relationships. 

Descriptive vs Somatic

Descriptive classifications are based almost exclusively on either descriptions of behavior as reported by various observers, such as parents, teachers, and medical personnel; or symptoms as reported by individuals themselves. As such, they are quite subjective, not amenable to verification by third parties, and not readily transferable across chronologic and/or cultural barriers.

Somatic nosology, on the other hand, is based almost exclusively on the objective histologic and chemical abnormalities which are characteristic of various diseases and can be identified by appropriately trained pathologists. While not all pathologists will agree in all cases, the degree of uniformity allowed is orders of magnitude greater than that enabled by the constantly changing classification embraced by the DSM system. Some models, like Functional Ensemble of Temperament suggest to unify nosology of somatic, biologically-based individual differences in healthy people (temperament) and their deviations in a form of mental disorders in one taxonomy 

Cultural differences

Classification schemes may not apply to all cultures. The DSM is based on predominantly American research studies and has been said to have a decidedly American outlook, meaning that differing disorders or concepts of illness from other cultures (including personalistic rather than naturalistic explanations) may be neglected or misrepresented, while Western cultural phenomena may be taken as universal. Culture-bound syndromes are those hypothesized to be specific to certain cultures (typically taken to mean non-Western or non-mainstream cultures); while some are listed in an appendix of the DSM-IV they are not detailed and there remain open questions about the relationship between Western and non-Western diagnostic categories and sociocultural factors, which are addressed from different directions by, for example, cross-cultural psychiatry or anthropology.

Historical development

Antiquity

In Ancient Greece, Hippocrates and his followers are generally credited with the first classification system for mental illnesses, including mania, melancholia, paranoia, phobias and Scythian disease (transvestism). They held that they were due to different kinds of imbalance in four humors.

Middle ages to Renaissance

The Persian physicians 'Ali ibn al-'Abbas al-Majusi and Najib ad-Din Samarqandi elaborated upon Hippocrates' system of classification. Avicenna (980−1037 CE) in the Canon of Medicine listed a number of mental disorders, including "passive male homosexuality". 

Laws generally distinguished between "idiots" and "lunatics". 

Thomas Sydenham (1624–1689), the "English Hippocrates", emphasized careful clinical observation and diagnosis and developed the concept of a syndrome, a group of associated symptoms having a common course, which would later influence psychiatric classification.

18th century

Evolution in the scientific concepts of psychopathology (literally referring to diseases of the mind) took hold in the late 18th and 19th centuries following the Renaissance and Enlightenment. Individual behaviors that had long been recognized came to be grouped into syndromes. 

Boissier de Sauvages developed an extremely extensive psychiatric classification in the mid-18th century, influenced by the medical nosology of Thomas Sydenham and the biological taxonomy of Carl Linnaeus. It was only part of his classification of 2400 medical diseases. These were divided into 10 "classes", one of which comprised the bulk of the mental diseases, divided into four "orders" and 23 "genera". One genus, melancholia, was subdivided into 14 "species".

William Cullen advanced an influential medical nosology which included four classes of neuroses: coma, adynamias, spasms, and vesanias. The vesanias included amentia, melancholia, mania, and oneirodynia. 

Towards the end of the 18th century and into the 19th, Pinel, influenced by Cullen's scheme, developed his own, again employing the terminology of genera and species. His simplified revision of this reduced all mental illnesses to four basic types. He argued that mental disorders are not separate entities but stem from a single disease that he called "mental alienation". 

Attempts were made to merge the ancient concept of delirium with that of insanity, the latter sometimes described as delirium without fever. 

On the other hand, Pinel had started a trend for diagnosing forms of insanity 'without delirium' (meaning hallucinations or delusions) – a concept of partial insanity. Attempts were made to distinguish this from total insanity by criteria such as intensity, content or generalization of delusions.

19th century

Pinel's successor, Esquirol, extended Pinel's categories to five. Both made a clear distinction between insanity (including mania and dementia) as opposed to mental retardation (including idiocy and imbecility). Esquirol developed a concept of monomania—a periodic delusional fixation or undesirable disposition on one theme—that became a broad and common diagnosis and a part of popular culture for much of the 19th century. The diagnosis of "moral insanity" coined by James Prichard also became popular; those with the condition did not seem delusional or intellectually impaired but seemed to have disordered emotions or behavior. 

The botanical taxonomic approach was abandoned in the 19th century, in favor of an anatomical-clinical approach that became increasingly descriptive. There was a focus on identifying the particular psychological faculty involved in particular forms of insanity, including through phrenology, although some argued for a more central "unitary" cause. French and German psychiatric nosology was in the ascendency. The term "psychiatry" ("Psychiatrie") was coined by German physician Johann Christian Reil in 1808, from the Greek "ψυχή" (psychē: "soul or mind") and "ιατρός" (iatros: "healer or doctor"). The term "alienation" took on a psychiatric meaning in France, later adopted into medical English. The terms psychosis and neurosis came into use, the former viewed psychologically and the latter neurologically.

In the second half of the century, Karl Kahlbaum and Ewald Hecker developed a descriptive categorizion of syndromes, employing terms such as dysthymia, cyclothymia, catatonia, paranoia and hebephrenia. Wilhelm Griesinger (1817–1869) advanced a unitary scheme based on a concept of brain pathology. French psychiatrists Jules Baillarger described "folie à double forme" and Jean-Pierre Falret described "la folie circulaire"—alternating mania and depression.

The concept of adolescent insanity or developmental insanity was advanced by Scottish Asylum Superintendent and Lecturer in Mental Diseases Thomas Clouston in 1873, describing a psychotic condition which generally afflicted those aged 18–24 years, particularly males, and in 30% of cases proceeded to "a secondary dementia".

The concept of hysteria (wandering womb) had long been used, perhaps since ancient Egyptian times, and was later adopted by Freud. Descriptions of a specific syndrome now known as somatization disorder were first developed by the French physician, Paul Briquet in 1859. 

An American physician, Beard, described "neurasthenia" in 1869. German neurologist Westphal, coined the term "obsessional neurosis" now termed obsessive-compulsive disorder, and agoraphobia. Alienists created a whole new series of diagnoses that highlighted single, impulsive behavior, such as kleptomania, dipsomania, pyromania, and nymphomania. The diagnosis of drapetomania was also developed in the Southern United States to explain the perceived irrationality of black slaves trying to escape what was thought to be a suitable role. 

The scientific study of homosexuality began in the 19th century, informally viewed either as natural or as a disorder. Kraepelin included it as a disorder in his Compendium der Psychiatrie that he published in successive editions from 1883.

"Psychiatrists of Europe! Protect your sanctified diagnoses!" Cartoon by Emil Kraepelin, 1896.

 

In the late 19th century, Koch referred to "psychopathic inferiority" as a new term for moral insanity. In the 20th century the term became known as "psychopathy" or "sociopathy", related specifically to antisocial behavior. Related studies led to the DSM-III category of antisocial personality disorder.

20th century

Influenced by the approach of Kahlbaum and others, and developing his concepts in publications spanning the turn of the century, German psychiatrist Emil Kraepelin advanced a new system. He grouped together a number of existing diagnoses that appeared to all have a deteriorating course over time—such as catatonia, hebephrenia and dementia paranoides—under another existing term "dementia praecox" (meaning "early senility", later renamed schizophrenia). Another set of diagnoses that appeared to have a periodic course and better outcome were grouped together under the category of manic-depressive insanity (mood disorder). He also proposed a third category of psychosis, called paranoia, involving delusions but not the more general deficits and poor course attributed to dementia praecox. In all he proposed 15 categories, also including psychogenic neurosis, psychopathic personality, and syndromes of defective mental development (mental retardation). He eventually included homosexuality in the category of "mental conditions of constitutional origin".^{[citation needed]}

The neuroses were later split into anxiety disorders and other disorders.

Freud wrote extensively on hysteria and also coined the term, "anxiety neurosis", which appeared in DSM-I and DSM-II. Checklist criteria for this led to studies that were to define panic disorder for DSM-III.

Early 20th century schemes in Europe and the United States reflected a brain disease (or degeneration) model that had emerged during the 19th century, as well as some ideas from Darwin's theory of evolution and/or Freud's psychoanalytic theories.

Psychoanalytic theory did not rest on classification of distinct disorders, but pursued analyses of unconscious conflicts and their manifestations within an individual's life. It dealt with neurosis, psychosis, and perversion. The concept of borderline personality disorder and other personality disorder diagnoses were later formalized from such psychoanalytic theories, though such ego psychology-based lines of development diverged substantially from the paths taken elsewhere within psychoanalysis. 

The philosopher and psychiatrist Karl Jaspers made influential use of a "biographical method" and suggested ways to diagnose based on the form rather than content of beliefs or perceptions. In regard to classification in general he prophetically remarked that: "When we design a diagnostic schema, we can only do so if we forego something at the outset … and in the face of facts we have to draw the line where none exists... A classification therefore has only provisional value. It is a fiction which will discharge its function if it proves to be the most apt for the time".

Adolph Meyer advanced a mixed biosocial scheme that emphasized the reactions and adaptations of the whole organism to life experiences. 

In 1945, William C. Menninger advanced a classification scheme for the US army, called Medical 203, synthesizing ideas of the time into five major groups. This system was adopted by the Veterans Administration in the United States and strongly influenced the DSM.

The term stress, having emerged from endocrinology work in the 1930s, was popularized with an increasingly broad biopsychosocial meaning, and was increasingly linked to mental disorders. The diagnosis of post-traumatic stress disorder was later created.

Mental disorders were first included in the sixth revision of the International Classification of Diseases (ICD-6) in 1949. Three years later, in 1952, the American Psychiatric Association created its own classification system, DSM-I.

The Feighner Criteria group described fourteen major psychiatric disorders for which careful research studies were available, including homosexuality. These developed as the Research Diagnostic Criteria, adopted and further developed by the DSM-III.

The DSM and ICD developed, partly in sync, in the context of mainstream psychiatric research and theory. Debates continued and developed about the definition of mental illness, the medical model, categorical vs dimensional approaches, and whether and how to include suffering and impairment criteria. There is some attempt to construct novel schemes, for example from an attachment perspective where patterns of symptoms are construed as evidence of specific patterns of disrupted attachment, coupled with specific types of subsequent trauma.

21st century

The ICD-11 and DSM-5 are being developed at the start of the 21st century. Any radical new developments in classification are said to be more likely to be introduced by the APA than by the WHO, mainly because the former only has to persuade its own board of trustees whereas the latter has to persuade the representatives of over 200 different countries at a formal revision conference. In addition, while the DSM is a bestselling publication that makes huge profits for APA, the WHO incurs major expense in determining international consensus for revisions to the ICD. Although there is an ongoing attempt to reduce trivial or accidental differences between the DSM and ICD, it is thought that the APA and the WHO are likely to continue to produce new versions of their manuals and, in some respects, to compete with one another.

Criticism

There is some ongoing scientific doubt concerning the construct validity and reliability of psychiatric diagnostic categories and criteria even though they have been increasingly standardized to improve inter-rater agreement in controlled research. In the United States, there have been calls and endorsements for a congressional hearing to explore the nature and extent of harm potentially caused by this "minimally investigated enterprise".

Other specific criticisms of the current schemes include: attempts to demonstrate natural boundaries between related syndromes, or between a common syndrome and normality, have failed; inappropriateness of statistical (factor-analytic) arguments and lack of functionality considerations in the analysis of a structure of behavioral pathology; the disorders of current classification are probably surface phenomena that can have many different interacting causes, yet "the mere fact that a diagnostic concept is listed in an official nomenclature and provided with a precise operational definition tends to encourage us to assume that it is a "quasi-disease entity" that can be invoked to explain the patient's symptoms"; and that the diagnostic manuals have led to an unintended decline in careful evaluation of each individual person's experiences and social context.

Psychodynamic schemes have traditionally given the latter phenomenological aspect more consideration, but in psychoanalytic terms that have been long criticized on numerous grounds.

Some have argued that reliance on operational definition demands that intuitive concepts, such as depression, need to be operationally defined before they become amenable to scientific investigation. However, John Stuart Mill pointed out the dangers of believing that anything that could be given a name must refer to a thing and Stephen Jay Gould and others have criticized psychologists for doing just that. One critic states that "Instead of replacing 'metaphysical' terms such as 'desire' and 'purpose', they used it to legitimize them by giving them operational definitions. Thus in psychology, as in economics, the initial, quite radical operationalist ideas eventually came to serve as little more than a 'reassurance fetish' (Koch 1992, 275) for mainstream methodological practice." According to Tadafumi Kato, since the era of Kraepelin, psychiatrists have been trying to differentiate mental disorders by using clinical interviews. Kato argues there has been little progress over the last century and that only modest improvements are possible in this way; he suggests that only neurobiological studies using modern technology could form the basis for a new classification.

According to Heinz Katsching, expert committees have combined phenomenological criteria in variable ways into categories of mental disorders, repeatedly defined and redefined over the last half century. The diagnostic categories are termed "disorders" and yet, despite not being validated by biological criteria as most medical diseases are, are framed as medical diseases identified by medical diagnoses. He describes them as top-down classification systems similar to the botanic classifications of plants in the 17th and 18th centuries, when experts decided a priori which visible aspects of plants were relevant. Katsching notes that while psychopathological phenomena are certainly observed and experienced, the conceptual basis of psychiatric diagnostic categories is questioned from various ideological perspectives.

Psychiatrist Joel Paris argues that psychiatry is sometimes susceptible to diagnostic fads. Some have been based on theory (overdiagnosis of schizophrenia), some based on etiological (causation) concepts (overdiagnosis of post-traumatic stress disorder), and some based on the development of treatments. Paris points out that psychiatrists like to diagnose conditions they can treat, and gives examples of what he sees as prescribing patterns paralleling diagnostic trends, for example an increase in bipolar diagnosis once lithium came into use, and similar scenarios with the use of electroconvulsive therapy, neuroleptics, tricyclic antidepressants, and SSRIs. He notes that there was a time when every patient seemed to have "latent schizophrenia" and another time when everything in psychiatry seemed to be "masked depression", and he fears that the boundaries of the bipolar spectrum concept, including in application to children, are similarly expanding. Allen Frances has suggested fad diagnostic trends regarding autism and Attention deficit hyperactivity disorder.

Since the 1980s, psychologist Paula Caplan has had concerns about psychiatric diagnosis, and people being arbitrarily "slapped with a psychiatric label". Caplan says psychiatric diagnosis is unregulated, so doctors aren’t required to spend much time understanding patients situations or to seek another doctor’s opinion. The criteria for allocating psychiatric labels are contained in the Diagnostic and Statistical Manual of Mental Disorders, which can "lead a therapist to focus on narrow checklists of symptoms, with little consideration for what is causing the patient’s suffering". So, according to Caplan, getting a psychiatric diagnosis and label often hinders recovery.

The DSM and ICD approach remains under attack both because of the implied causality model and because some researchers believe it better to aim at underlying brain differences which can precede symptoms by many years.