Differing models of classification of disorders-

prototypal and dimensional approach; and Unresolved

issues in DSM-5 a critical approach.

Dr. Subhash Meena

 What is Classification?

► Classification (taxonomy) is 'the activity of ordering or

arrangement of objects into groups or sets based on their
relationships.
► Recognizing similarities and ordering objects into sets on the
basis of relationships constitute a fundamental cognitive
activity underlying concept formation and naming.
 Importance of classification of disorders

► Allows professionals to recognize patterns among the symptoms that people present (i.e.,
syndromes).

► Serves as an agreed upon authority that determines a threshold for impairment and/or distress
that warrants a diagnosis as well as recovery from the diagnosis.

► Provides a set of nouns, which may aid quick and efficient communication among
professionals, patients, families, insurance companies, public health officials, researchers,
and the general public.

► Organizes mental health conditions and disorders into groups and structures that allow users
of the diagnostic manual to find a disorder for which they are looking.
 Importance of classification of disorders

► Aids public health care in the identification of individuals in need of service, make
informed choices about how best to allocate the system's resources, and decide of who
qualifies for service (e.g., insurance reimbursement and universal health care).

► Informs treatment planning, target of treatment, and clinical management of people with
mental health conditions.

► Defines which behaviors a society is willing to accept and which are not tolerated (e.g.,
antisocial behavior).

► According to WHO's vision for the ICD-11 (for all diseases, conditions, and disorders),
the most superior purpose of assigning a diagnosis is to ease suffering.
Approaches to classification
1. PROTOTYPAL
2. DIMENSIONAL
3. CATEGORICAL
 Prototypal Approach

► Prototype in psychology is referred to as a 'theoretical ideal' or 'the perfect case' providing a standard
against which real individuals assigned to a classification category could be evaluated.
► The process of classifying abnormal behavior on the assumption that there are combinations of
characteristics (prototypes of behavior disorders) that tend to occur together regularly. (APA)
► Comparing a patient’s overall clinical presentation to a set of diagnostic prototypes – for clinical use,
paragraph-length descriptions of empirically identified disorders.
► Clinicians are presented with what are usually paragraph-length descriptions of a disorder, often with
an additional set of considerations, and are instructed to diagnose the patient based on their
knowledge of the patient at the time (e.g., after a single session or months of treatment) with
whatever degree of certainty they feel comfortable.
► Prototypal approach is flexible rather than strict criteria-based diagnosis.
 Advantages of Prototype Approach

► It better fits the ways humans naturally think and classify.

► Novel opportunities for refining psychiatric classifications arise out of
statistical models based on the concept of prototype as an alternative or
complement to the conventional approach to defining categories as units
of classification.
► It has a clinical utility.
► Whereas dimensional diagnosis is probably most precise in most cases,
and categorical diagnosis is most familiar and feels most “natural”,
prototype diagnosis captures the advantages of both.
 Advantages of Prototype Approach

It allows greater flexibility and validity not only in the diagnostic process but also in the
definitions of disorders and the criteria that can be included in the prototypes.

The advantage of prototype diagnosis is its utility in integrating teaching, training, and
subsequent clinical experience. The goal of prototype diagnosis is to help clinicians develop
mental representations of different kinds of disorder and, equally important, to standardize those
representations across diagnosticians. Instead of trying to memorize symptom lists, the goal is to
form mental representations of coherent syndromes, in which signs and symptoms are
functionally related.
 Disadvantages of Prototypal Approach

► It could foster confirmatory biases and other heuristics that can lead
clinicians, like all humans, to see what they expect to see or to stick
with hypotheses about a patient despite disconfirming information.
 Dimensional Approach

► Allows a clinician more latitude to assess the severity of a condition and does not
imply a concrete threshold between “normality” and a disorder.
► The dimensional model views various personality features along several continuous
dimensions (or continuums).
► It focuses on the extent in which the person has a disorder. Many disorders are simply
normal traits gone too far. (personality disorders)
► It is not a process of deciding the presence or absence of a symptom or a disorder, but
rather, the degree to which a particular characteristic is present.
► Variations in symptomatology can be represented by a set of dimensions.
► For example, Blood Pressure is measured along a continuum from low to high.
 Dimensional Approach

• Patients is profiled by grading the severity of symptoms from a number of dimensions in comparison to the
population e.g anxiety, variations in mood, etc.
• Symptoms can be monitored over time(transitional)- to determine the effectiveness of treatment.
• Dimensionality can be envisaged in terms of number of symptoms (e.g five out of eight symptoms to
diagnose major depressive disorder ) and severity of each symptom group ( mild, moderate and severe).
• This approach classifies the mental disorders that quantifies a person’s symptoms with numerical values on
one or more scales category.
• Diagnosis then become not a process of deciding the presence or absence of a symptom or disorder but
rather the degree to which a particular characteristic is present. The dimensional approach suggests that
symptom may be present in normal as well as in ill.
 Advantages of Dimensional Approach

► It generates richer data, i.e. we get more detail of a case-by-case approach for
individual patients.
► It would better be able to capture the complexities of a person’s life that a
categorical approach would miss.
► Classifies disorder on its severity, not just its presence.
► Stigma from labeling is less likely to occur. (For e.g. “she is anxious”, not
“she has a borderline personality disorder”).
 Advantages of Dimensional Approach

► Dimensional approach avoids setting of particular thresholds for

distinguishing between pathology and normality.
► Research studies using dimensional scales have greater power to detect
differences in group.
► E.g. Individuals who present with depression, anxiety, and social avoidance.
The dimensional approach may simply indicate that the person has elevated
values on depression, anxiety, and social avoidance.
► It facilitate research into the underlying etiology and path-physiology of
mental disorders.
► Decisions about the management of individual patients are easier to make if
the patient is thought of having a particular disorder.
 Disadvantages of Dimensional Approach

► The value of dimensions in terms of communicating information from

one clinician to another is likely to be quite limited.
► Clinicians are accustomed to thinking in terms of diagnostic categories.
► Existing knowledge base about the presentation, etiology, epidemiology,
course, prognosis, and treatment is based on these categories.
 Categorical Approach

• It involves the assessment of whether an individual has disorder on the basis of symptoms
and characteristics that is described as typical of the disorder. Thus approach is the
classification strategies used in DSM and ICD.
• The DSM names the disorders and describes them in specific terms.
• The ICD identifies symptoms that indicate the presence of a disorder.
• Thoughts, feelings and behaviour can be organized into categories representing disorders.
• All or nothing principle. This approach considers illness as being present or absent
• There are no “in between” diagnosis ( so individual either has a diagnosable mental
disorder or doesn’t have a diagnosable disorder)
 Categorical Approach

► The system used to classify and diagnose mental disorders is both valid and reliable (this
classification system actually organises mental disorder into discrete and distinct disorders
and that the classification system produces the same diagnosis each time it is used in the
same situation).

► Categorical approaches have been criticized somewhat, with critics stating that they do not
adequately address several critical elements of disorders in their diagnoses, such as
individual differences in severity, the variability of contributing factors, variances in
appearance of various disorders, and comorbidity with other disorders.
 Categorical Approach
► Strengths and Weaknesses
• Categorical typologies are firmly entrenched forms of representation of medical diagnoses. As such, they have both
practical and conceptual advantages. They are familiar to clinicians, as a good deal of existing knowledge about the
causes, presentation, treatment and prognosis of mental disorders has been generated and stored by using categories.
They are easy to use under conditions of incomplete clinical information; and they have the capacity to 'restore the
unity of the patient's pathology by integrating seemingly diverse elements into a single, coordinated configuration.
• Helps communication
► Weakness of this approach include :
• Lots of overlap between symptoms which can make diagnosis tricky
• Stigma and labelling
 Categorical VS Dimensional

► Disorders included in DSM/ICD are defined categorically.

► Diagnostic criteria are provided for each disorder.
► They indicate if the clinical presentation either meets or does not meet the definitional
requirements for a particular disorder.
► This method of classification is similar to one that is used in medicine.
► For e.g. The patient either has or does not have pneumonia.
► This tendency to define illness in terms of categories reflects basic human thought
processes.
► For e.g. The use of nouns in everyday speech to indicate categories of “things” (chairs,
table, dogs, cats)
 Current approach used in DSM-5

► The Diagnostic and Statistical Manual of Mental Disorders (DSM-5) introduces

the integration of a dimensional approach to diagnosis and classification with the
current categorical approach.
► Previous editions of the DSM used a strictly categorical model requiring a
clinician to determine whether a disorder was present or absent.
► The dimensional approach, which allows a clinician more latitude to assess the
severity of a condition and does not imply a concrete threshold between
“normality” and a disorder, is now incorporated via select diagnoses.
 Current approach used in DSM-5

► For example, autism spectrum disorder (ASD) combines four different categorical
disorders and conceptualizes them as occurring along a single spectrum focused on
dysfunctional social communication and restricted, repetitive behaviors or interests. Under
DSM-IV, patients with such symptoms could be diagnosed with autistic disorder,
Asperger’s disorder, childhood disintegrative disorder, or the catch-all diagnosis of
pervasive developmental disorder not otherwise specified. But the diagnoses were not
consistently applied across practices and treatment centers, in large part because they
shared such similar characteristics. Researchers determined that these separate disorders
are actually related conditions along a single continuum of behavior. With ASD, some
individuals show mild symptoms and others have much more severe symptoms. This
spectrum will allow clinicians to account for such variations from person to person.
 Unresolved Issues in DSM-5

► The DSM was first published in 1952 when the US armed forces wanted a guide on the diagnosis of
servicemen. There was also an increasing push against the idea of treating people in institutions.
Because our understanding of mental health is evolving, the DSM is periodically updated. In each
revision, mental health conditions that are no longer considered valid are removed, while newly
defined conditions are added.
• The Board of Trustees of the American Psychiatric Association has given its final approval to a
deeply flawed DSM-5 containing many changes that seem clearly unsafe and scientifically
unsound…Our patients deserve better, society deserves better, and the mental health professions
deserve better.” (Frances, 2012b).
 Unresolved Issues in DSM-5

• “With the DSM-5, patients worried about having a medical illness will often be diagnosed with
somatic symptom disorder, normal grief will be misidentified as major depressive disorder, the
forgetfulness of old age will be confused with mild neurocognitive disorder, temper tantrums will be
labeled disruptive mood dysregulation disorder, overeating will become binge eating disorder, and
the already overused diagnosis of attention-deficit disorder will be even easier to apply” .
 Unresolved Issues in DSM-5

► In an article entitled DSM 5 Is Guide Not Bible – Ignore its Ten Worst Changes Professor
Allen Frances highlighted changes to the manual that he argued were examples of
over-medicalisation of mental health. These changes included:
• Asperger’s syndrome
• Disruptive mood dysregulation disorder
• Mild cognitive disorder
• Generalised anxiety disorder
• Major depressive disorder
 Unresolved Issues in DSM-5

• Asperger’s syndrome
► The diagnosis of Asperger’s syndrome has been removed from the DSM-5 and is now part of one
umbrella term “Autism spectrum disorder”. This is hugely controversial as, according to the ICD-10,
those suffering from Asperger’s syndrome have “no general delay or retardation in language or in
cognitive development”.
• Disruptive mood dysregulation disorder
► Disruptive mood dysregulation disorder (DMDD) is defined by DSM-5 as severe and recurrent
temper outbursts (three or more times a week) that are grossly out of proportion in intensity or
duration in children up to the age of 18. This definition is said to be based on a single piece of
research, so it is not clear how it might apply to people seeking medical or psychological help for
mental health problems in the “real world”.
 Unresolved Issues in DSM-5

• Mild cognitive disorder

► Mild cognitive disorder (MCD) is defined as “a level of cognitive decline that requires compensatory
strategies to help maintain independence and perform activities of daily living.”
► The DSM-5 makes it clear that this decline goes beyond that usually associated with ageing. Despite
this, the concept of mild cognitive disorder has been attacked. The main criticism is that there is little
in the way of effective treatment for MCD, but if people are diagnosed with the condition it may
cause needless stress and anxiety. People diagnosed with MCD may worry that they will go on to
develop dementia, when this may not be the case.
 Unresolved Issues in DSM-5

• Generalised anxiety disorder

► The “diagnostic threshold” for generalised anxiety disorder (GAD) was lowered in the new version of
the manual.
► In previous versions, GAD was defined as having any three of six symptoms (such as restlessness, a
sense of dread, and feeling constantly on edge) for at least three months. In DSM-5, this has been
revised to having just one to four symptoms for at least one month.
► Critics suggest that this lowering of the threshold could lead to people with “everyday worries” as
being misdiagnosed and needlessly treated.
 Unresolved Issues in DSM-5

• Major depressive disorder

► The most scathing criticism of DSM-5 has been reserved for changes to what constitutes major
depressive disorder (MDD).
► previous definitions described MDD as a persistent low mood, loss of enjoyment and pleasure, and a
disruption to everyday activity. However, these definitions also specifically excluded a diagnosis of
MDD if the person was recently bereaved. This exception has been removed in DSM-5.
► A wide range of individuals and organisations have argued that the DSM-5 is in danger of
“medicalising grief”. The argument expressed is that grief is a normal, if upsetting, human process
that should not require treatment with drugs such as antidepressants.
 Unresolved Issues in DSM-5

► The DSM-5 promotes the idea that for most psychological disorders, there is a genetic component,
yet there is no known gene variant for about 97% of diagnoses.
► The DSM-5 also perpetuates the chemical imbalance theory, which is the idea that mental
disorders are caused by an imbalance of chemicals in the brain. However, the theory is entirely
hypothetical.
► To develop the DSM-5, committees of mental health experts made decisions about disorders based
on clusters of symptoms. However, these experts carried with them implicit cultural biases about
which behaviors should be considered normal versus abnormal. However, the experts were not aware
of their own biases, which in practice has led to arbitrary, and often invalid, diagnoses.
► There has not been a clear empirical assessment of how well the disorder classification system
separates individuals into groups based on symptom criteria.
Thank you