{"id":1263,"date":"2020-08-25T19:20:44","date_gmt":"2020-08-25T19:20:44","guid":{"rendered":"https:\/\/courses.lumenlearning.com\/abnormalpsych\/?post_type=chapter&#038;p=1263"},"modified":"2022-07-26T20:06:49","modified_gmt":"2022-07-26T20:06:49","slug":"classification-and-labeling","status":"publish","type":"chapter","link":"https:\/\/courses.lumenlearning.com\/wm-abnormalpsych\/chapter\/classification-and-labeling\/","title":{"raw":"Classification and Labeling","rendered":"Classification and Labeling"},"content":{"raw":"<div class=\"textbox learning-objectives\">\r\n<h3>Learning Objectives<\/h3>\r\n<ul>\r\n \t<li>Discuss arguments and objections surrounding the <em>DSM<\/em> classification system<\/li>\r\n \t<li>Describe problems associated with classification and labeling<\/li>\r\n<\/ul>\r\n<\/div>\r\n<h2 class=\"ls\">Advantages and Disadvantages of the\u00a0DSM\u20105 Classification System<\/h2>\r\nWith any system of classification like\u00a0<em>DSM\u20105<\/em>, there will always be strengths and weaknesses. One of the major strengths of the\u00a0<em>DSM<\/em>\u00a0system is the wide acceptance and use of the system. Mental health professionals in the United States routinely utilize\u00a0<span style=\"font-size: 1em;\">diagnostic systems\u00a0<\/span><span style=\"font-size: 1rem; text-align: initial;\">in their work\u00a0<\/span><span style=\"font-size: 1em; text-align: initial;\">if for no other reason than to allow their clients to receive treatment in hospitals and reimbursement from health care providers.\u00a0<\/span>Each category of disorder has a numeric code taken from the\u00a0<em>ICD<\/em> coding system, used for health service (including insurance) administrative purposes.\r\n\r\nThe limitations of the\u00a0<em>DSM<\/em>\u00a0system are reflected in the terminology related to diagnosis itself. Since the DSM-3,\u00a0the goal was to improve the uniformity and validity of psychiatric diagnosis in the wake of a number of critiques, including the famous\u00a0<strong>Rosenhan experiment <\/strong>(see box below). There was also felt a need to standardize diagnostic practices within the United States and with other countries, after research showed that psychiatric diagnoses differed between Europe and the United States.[footnote]Cooper, JE; Kendell, RE; Gurland, BJ; Sartorius, N; Farkas, T (April 1969). \"Cross-national study of diagnosis of the mental disorders: some results from the first comparative investigation\". <em>The American Journal of Psychiatry<\/em>. 125 (10 Suppl): 21\u20139. doi:10.1176\/ajp.125.10s.21. PMID 5774702. Archived from the original on 2010-08-24.[\/footnote]\r\n<div class=\"textbox exercises\">\r\n<h3>A closer look: The Rosenhan Experiment<\/h3>\r\nThe Rosenhan experiment was carried out by\u00a0David Rosenhan,\u00a0a Stanford University professor, and published by the journal\u00a0<em>Science<\/em>\u00a0in 1973 under the title\u00a0\u201cOn Being Sane in Insane Places.\"<span style=\"font-size: 1rem; text-align: initial;\">\u00a0It was an experiment conducted to determine the reliability and validity of\u00a0psychiatric\u00a0diagnosis. The experimenters feigned hallucinations to enter psychiatric hospitals, and acted normally afterwards. They were diagnosed with psychiatric disorders and were given\u00a0antipsychotic\u00a0drugs. <\/span>\r\n\r\n<span style=\"font-size: 1rem; text-align: initial;\">The study was c<\/span><span style=\"text-align: initial;\"><span style=\"font-size: 1rem;\">onsidered an important and influential criticism of psychiatric diagnosis.\u00a0It has been argued that the experiment was fabricated;\u00a0<\/span>nonetheless<span style=\"font-size: 1rem;\">, the study concluded, \u201cit is clear that we cannot distinguish the sane from the insane in psychiatric hospitals,\u201d and it also illustrated the dangers of\u00a0dehumanization\u00a0and labeling in psychiatric institutions. It suggested that the use of community mental health facilities that concentrated on specific problems and behaviors rather than psychiatric labels might be a solution, and recommended education to make psychiatric workers more aware of the social psychology of their facilities.<\/span><\/span>\r\n\r\n<a href=\"https:\/\/www.youtube.com\/watch?v=D8OxdGV_7lo&amp;feature=emb_logo\" target=\"_blank\" rel=\"noopener\">Here is a seven-minute video summing up the study<\/a>.\r\n\r\n<\/div>\r\n<h2>Reliability and Validity<\/h2>\r\nThe revisions and refinements in the <em>DSM<\/em> classification system have been largely driven by the need to improve reliability and validity. <strong>Reliability<\/strong> measures how consistent a diagnosis is and how reliably the categories can be judged. <strong>Validity<\/strong> looks at how accurate the diagnosis is and how valid the categories are in the sense of discriminating among disorders that have distinctive etiologies and possibly require different treatments.\r\n<div class=\"textbox exercises\">\r\n<h3>Reliability Vs. Validity<\/h3>\r\n[embed]https:\/\/lumenlearning.h5p.com\/content\/1290477372809028568\/embed[\/embed]\r\n\r\n<\/div>\r\nTo be useful, any diagnostic system must demonstrate\u00a0<strong>reliability<\/strong>\u00a0and\u00a0<strong>validity<\/strong>. The revisions of the <em>DSM<\/em> from the third edition forward have been mainly concerned with\u00a0<strong>diagnostic reliability<\/strong>\u2014the degree to which different diagnosticians agree on a diagnosis.\u00a0If clinicians and researchers frequently disagree about the diagnosis of a patient, then research into the causes and effective treatments of those disorders cannot advance. To\u00a0be considered reliable, or consistent, different evaluators using the system should arrive at the same diagnoses when they evaluate the same people.<span style=\"font-size: 1rem; text-align: initial;\">\u00a0<\/span><span style=\"font-size: 1em;\">For example, a diagnosis of\u00a0<\/span><span style=\"font-size: 1em;\">major depressive disorder<\/span><span style=\"font-size: 1em;\">, a common mental illness, had a poor reliability\u00a0<\/span><span style=\"font-size: 1em;\">kappa<\/span><span style=\"font-size: 1em;\">\u00a0statistic of 0.28, indicating that clinicians frequently disagreed on diagnosing this disorder in the same patients. The most reliable diagnosis was major neurocognitive disorder, with a kappa of 0.78.[footnote]Freedman, Robert; Lewis, David A.; Michels, Robert; Pine, Daniel S.; Schultz, Susan K.; Tamminga, Carol A.; Gabbard, Glen O.; Gau, Susan Shur-Fen; Javitt, Daniel C.; Oquendo, Maria A.; Shrout, Patrick E.; Vieta, Eduard; Yager, Joel (January 2013). \"The Initial Field Trials of <em>DSM-5<\/em>: New Blooms and Old Thorns.\"\u00a0<em>American Journal of Psychiatry<\/em>. 170 (1): 1\u20135. doi:10.1176\/appi.ajp.2012.12091189. PMID 23288382. Archived from the original on 2013-01-15.[\/footnote]<\/span><sup id=\"cite_ref-61\" class=\"reference\"><\/sup>\r\n\r\nCritics assert, for example, that many <em>DSM-5<\/em> revisions or additions lack empirical support;\u00a0<strong>inter-rater<\/strong> <strong>reliability, <\/strong>or\u00a0the degree of agreement among raters,\u00a0is low for many disorders; several sections contain poorly written, confusing, or contradictory information; and the psychiatric drug industry unduly influenced the manual's content (many <em>DSM-5<\/em> workgroup participants had ties to pharmaceutical companies).<sup id=\"cite_ref-2\" class=\"reference\"><\/sup>footnote]Welch, Steven; Klassen, Cherisse; Borisova, Oxana; Clothier, Holly (2013). \"The <em>DSM-5<\/em> controversies: How should psychologists respond?\". Canadian Psychology. 54(3): 166\u2013175. doi:10.1037\/a0033841[\/footnote]\r\n\r\n<strong>Diagnostic\u00a0validity<\/strong>\u00a0concerns\u00a0whether\u00a0the\u00a0diagnosis\u00a0measures\u00a0what\u00a0it\u00a0claims\u00a0to\u00a0measure. In psychiatry, there\u00a0is a particular issue with assessing the validity of the\u00a0diagnostic categories\u00a0themselves. In this context,\r\n<ul>\r\n \t<li><strong>content validity<\/strong> may refer to symptoms and diagnostic criteria.<\/li>\r\n \t<li><strong>concurrent validity<\/strong>\u00a0looks at whether the markers that indicate a disorder actually correlate with the disorder, and if these markers are true over time and across multiple people and measures. It may also look at the appropriate alignment of a treatment response to a disorder.<\/li>\r\n \t<li><strong>predictive validity<\/strong> may refer mainly to diagnostic stability over time and\u00a0the relationship between the diagnosis and the ability to predict people\u2019s behavior in certain situations.<\/li>\r\n \t<li><strong>discriminant validity<\/strong> may involve delimitation from other disorders.<\/li>\r\n<\/ul>\r\nRobins and Guze proposed in 1970 what were to become influential formal criteria for establishing the validity of psychiatric diagnoses. The five phases of diagnostic validation used by Robins and Guze were (1) clinical characteristics of the syndrome and of the patients who develop it (including core symptoms, demographic characteristics, and precipitating factors); (2) exclusionary criteria differentiating the syndrome from other known disorders; (3) family studies; (4) laboratory data (radiological, chemical, pathologic, and psychological evidence); and (5) follow-up studies (for diagnostic stability, course, and treatment response).[footnote]Sur\u00eds, A., Holliday, R., &amp; North, C. S. (2016). The Evolution of the Classification of Psychiatric Disorders. Behavioral sciences (Basel, Switzerland), 6(1), 5. https:\/\/doi.org\/10.3390\/bs6010005[\/footnote] Once the characteristics of disorder, the exclusionary criteria, family, lab, and follow-up studies are completed, there should be enough information to deem the <em>DSM<\/em> content as a valid description of the mental disorder.\r\n\r\n[caption id=\"attachment_4707\" align=\"alignright\" width=\"282\"]<img class=\"wp-image-4707\" src=\"https:\/\/s3-us-west-2.amazonaws.com\/courses-images\/wp-content\/uploads\/sites\/5351\/2020\/08\/24043156\/hospital-3098683_1920-300x200.jpg\" alt=\"A room in a hospital where MRI (magnetic resonance imaging) is being performed.\" width=\"282\" height=\"188\" \/> <strong>Figure 1.<\/strong> Radiology laboratory studies like MRIs are included in the criteria for validity.[\/caption]\r\n\r\nThese were incorporated into the\u00a0Feighner Criteria\u00a0and\u00a0Research Diagnostic Criteria\u00a0that have since formed the basis of the <em>DSM<\/em> and <em>ICD<\/em> classification systems.\u00a0[footnote]Kendell, R; Jablensky, A (2003). \"Distinguishing between the validity and utility of psychiatric diagnoses\". The American Journal of Psychiatry. 160 (1): 4\u201312. doi:10.1176\/appi.ajp.160.1.4. PMID 12505793[\/footnote]\r\n\r\nOther critics also believe the\u00a0<em>DSM<\/em>\u00a0needs to become more sensitive to the importance of cultural and ethnic factors in diagnostic assessment.\u00a0They encourage us to consider and understand that the symptoms or problem behaviors included as diagnostic criteria in the\u00a0<em>DSM<\/em>\u00a0were largely determined by a consensus of mostly U.S.-trained psychiatrists, psychologists, and social workers. Imagine that the American Psychiatric Association had asked Asian-trained or Latin American\u2013trained professionals to develop their diagnostic manual? Might there might have been different diagnostic criteria or even different diagnostic categories? [footnote]Alarc\u00f3n, R. D., Becker, A. E., Lewis-Fern\u00e1ndez, R., Like, R. C., Desai, P., Foulks, E.,\u2009.\u2009.\u2009.\u2009Primm, A. (2009). Issues for <em>DSM-5<\/em>: The role of culture in psychiatric diagnosis. <em>The Journal of Nervous and Mental Disease<\/em>, 197, 559\u2013660. doi:10.1097\/NMD.0b013e3181b0cbff[\/footnote]\r\n\r\n<span style=\"font-size: 1em;\">Overall, the bulk of limitations of the\u00a0<em>DSM<\/em>\u00a0system listed so far are related to the diagnostic system in general.\u00a0It is worthwhile to be alert to the criticisms of the <em>DSM<\/em> system, particularly since they serve as a reminder that mental health professionals aim to help\u00a0<span style=\"font-size: 1em;\">the individual\u00a0<\/span><span style=\"font-size: 1em;\">and not the disorder. Furthermore, t<\/span>he\u00a0<em>DSM<\/em>\u00a0system has been useful to\u00a0<\/span><span style=\"font-size: 1em;\">insurance companies who adopt its use to establish coverage for certain clinical disorders, and has been\u00a0<\/span><span style=\"font-size: 1rem; text-align: initial;\">helpful in allowing researchers and clinicians to have a common language with which to discuss clients.\u00a0<\/span>\r\n<div class=\"textbox tryit\">\r\n<h3>Try It<\/h3>\r\nhttps:\/\/assess.lumenlearning.com\/practice\/39ff7e80-39e4-4821-ad0c-4cd6045fc4b4\r\n\r\nhttps:\/\/assess.lumenlearning.com\/practice\/27c70fbb-9564-4a61-80a3-cd44ab449522\r\n\r\n<\/div>\r\n<h2>Differences between Categorical and Dimensional Understanding of Behavior<\/h2>\r\nBoth the\u00a0<em>DSM<\/em>\u00a0and\u00a0<em>ICD<\/em>\u00a0systems represent a\u00a0<span class=\"keyTerm ls2\"><b>categorical approach<\/b><\/span>\u00a0to the description of mental disorders. As the name implies, a categorical approach attempts to categorize mental disorders into distinct diagnoses. The categorical approach is based on the idea that a person either meets criteria for a specific disorder or they do not.\u00a0<span style=\"font-size: 1em;\">Traditional categorical models of classification, which are based on the\u00a0<\/span><span style=\"font-size: 1em;\">presence or absence of\u00a0<\/span><span style=\"font-size: 1em;\">symptoms,\u00a0<\/span><span style=\"font-size: 1em;\">do not take into account levels of expression of a characteristic or the presence of any underlying <strong>dimension<\/strong>.\u00a0<\/span><span style=\"text-align: initial;\"><span style=\"font-size: 1rem;\">This conceptualization allows a mental <\/span>health<span style=\"font-size: 1rem;\">\u00a0professional to make a dichotomous decision (i.e., yes, the person meets criteria or no, the person does not meet criteria for that disorder). A<\/span><\/span><span style=\"font-size: 1rem; text-align: initial;\">\u00a0<em>dimension<\/em>\u00a0refers to a continuum on which an individual can have various levels of a characteristic, in contrast to the\u00a0<\/span><span style=\"font-size: 1rem; text-align: initial;\">dichotomous<\/span><span style=\"font-size: 1rem; text-align: initial;\">\u00a0categorical approach in which an individual does or does not possess a characteristic<\/span><span style=\"font-size: 1rem; text-align: initial;\">.\u00a0<\/span>\r\n\r\nThe\u00a0<em>DSM-4<\/em> organized diagnoses using five separate axes (clinical disorders, personality disorders, general medical disorders, and then sections on psychosocial and environmental factors, and the global assessment of functioning (which measured the severity of a disorder). An\u00a0<b>axis<\/b>\u00a0is defined as a category of information regarding one dimension of an individual's functioning. In the <em>DSM-IV-TR<\/em> system, an individual was diagnosed on five different domains, or \"axes.\" The <em>DSM-5<\/em> got rid of the axis system, as there was no scientific justification for grouping things by axis. Originally, the\u00a0<b>multiaxial system<\/b>\u00a0was intended to allow professionals to characterize clients in a multidimensional way (medical, psychological, developmental, and environmental\/social status), but rationale for removal of the multi-axial system was based on unclear boundaries between medical and psychiatric diagnoses, inconsistent use of Axis IV by clinicians and researchers (psychosocial and environmental problems), and poor psychometric and clinical validity of Axis V (Global Assessment of Functioning).[footnote]Sur\u00eds, A.; Holliday, R.; North, C.S. <em>The Evolution of the Classification of Psychiatric Disorders<\/em>.\u00a0<em>Behav. Sci.<\/em>\u00a02016,\u00a0<em>6<\/em>, 5.[\/footnote]\r\n\r\nThe most important change in <em>DSM-5<\/em> was the inclusion of dimensions in diagnoses; for example, how severely ill is a patient with schizophrenia or depression? The dimensional approach focuses on\u00a0<span style=\"font-size: 1em;\">varying levels of different behaviors that a person exhibits, r<\/span><span style=\"font-size: 1rem; text-align: initial;\">ather than whether or not a person meets criteria for a particular disorder.\u00a0<\/span><span style=\"font-size: 1rem; text-align: initial;\">T<\/span>he <strong>dimensional approach<\/strong> is also included in Section III (\"Emerging Measures and Models\"). This section<span style=\"font-size: 1em;\">\u00a0includes assessment measures and diagnoses not considered well-established enough to be part of the main system. For example,\u00a0<\/span>an \"Alternative DSM-5 Model for Personality Disorders\" is described.[footnote]American Psychiatric Association (2013). <em>Diagnostic and Statistical Manual of Mental Disorders<\/em>, Fifth Edition. World Psychiatry. 14. pp. 234\u2013236.[\/footnote]\u00a0The decision to retain the old <em>DSM-4<\/em> categorical model for personality disorders in <em>DSM-5<\/em> was controversial (currently the ten personality disorders are grouped into three general categories), and efforts continue to persuade the\u00a0American Psychiatric Association\u00a0to replace it with the dimensional model in <em>DSM 5.1.\u00a0<\/em>[footnote]Skodol, Andrew E.; Leslie C. Morey; Donna S. Bender; John M. Oldham (2013). \"The ironic fate of the personality disorders in <em>DSM-5<\/em>.\" <em>Personality Disorders: Theory, Research, and Treatment<\/em>. 4 (4): 342\u2013349.[\/footnote]<sup id=\"cite_ref-3\" class=\"reference\"><\/sup>\r\n\r\nSince the categorical model is widely used in clinical practice and has a significant body of research supporting it, its common usage is compelling to laypeople when they are judging the credibility of professional opinion. Therefore, the dimensional approach is often further criticized for being difficult to interpret and less accessible. It is, however, widely used in some professional settings as the established approach, for example by\u00a0forensic psychologists.\u00a0[footnote]Weiner, Irving B. (2003). Handbook of Psychology, Volume 11, Forensic Psychology. 11. Hoboken, NJ: Wiley. pp. 120\u2013121.[\/footnote]<sup id=\"cite_ref-Weiner11_11-0\" class=\"reference\"><\/sup>\r\n\r\nRegardless of whether you use a categorical or dimensional approach to understand a person's functioning, it is crucial to remember that behavior can change over time.\r\n<h2>Problems Associated with Classification and Labeling<\/h2>\r\nFinally, but probably most importantly, any diagnostic system such as the\u00a0DSM\u00a0system allows for individuals to be labeled for behavior that may or may not be an important part of their character.\u00a0<span class=\"keyTerm ls2\"><b>Labeling<\/b><\/span>\u00a0occurs when information about a person's diagnostic classification is communicated in a negative manner that leads to stigma for the individual with a mental disorder.\r\n<h2><span id=\"The_&quot;mentally_ill&quot;\" class=\"mw-headline\">The \"Mentally Ill\"<\/span><\/h2>\r\nThe social construction of\u00a0deviant behavior\u00a0plays an important role in the labeling process that occurs in society. This process involves not only the labeling of criminally deviant behavior, which is behavior that does not fit socially constructed norms, but also labeling that which reflects stereotyped or stigmatized behavior of the \"mentally ill.\" The <strong>labeling theory<\/strong> was first applied to the term <em>\"<\/em>mentally ill\" in 1966 when\u00a0Thomas J. Scheff\u00a0published\u00a0<i>Being Mentally Ill<\/i>. Scheff challenged common perceptions of\u00a0mental disorders\u00a0by claiming that mental disorder is manifested solely as a result of societal influence. Scheff argued that society views certain behaviors and actions as\u00a0deviant\u00a0and, in order to come to terms with and understand these actions, often places the label of mental disorder on those who exhibit them. Certain expectations are then placed on these individuals and, over time, they unconsciously change their behavior to fulfill them. Criteria for different mental illnesses are not consistently fulfilled by those who are diagnosed with them because all of these people suffer from the same disorder, they are simply fulfilled because the <em>\"mentally ill\"<\/em> believe they are supposed to act a certain way so, over time, come to do so.[footnote]Scheff, Thomas J. 1984. Being Mentally Ill (2nd ed.). Piscataway: Aldine Transaction.[\/footnote]\r\n\r\nScheff's theory had many critics, most notably\u00a0Walter Gove\u00a0who consistently argued against Scheff with an almost opposite theory; he believed that society has no influence at all on mental disorder. Instead, any societal perceptions of the <em>\"mentally ill\"<\/em> come about as a direct result of these people's behaviors. Most sociologists' views of labeling and mental disorder have fallen somewhere between the extremes of Gove and Scheff. On the other hand, it is almost impossible to deny, given both common sense and research findings, that society's negative perceptions of \"crazy\" people has had some effect on them. It seems that, realistically, labeling can accentuate and prolong the issues termed \"mental illness\", but it is rarely the full cause.[footnote]Gove, Walter R. (1975). Labelling of Deviance: Evaluating a Perspective. Hoboken: John Wiley &amp; Sons Inc.[\/footnote]\r\n\r\n<b>Labeling theory<\/b>\u00a0posits that\u00a0self-identity\u00a0and the behavior of individuals may be determined or influenced by the terms used to describe or classify them. It is associated with the concepts of\u00a0<strong>self-fulfilling prophecy<\/strong>\u00a0and\u00a0<strong>stereotyping<\/strong>.\u00a0However, the label of<em> \"<\/em>mentally ill<em>\"<\/em> may help a person seek help, for example, psychotherapy\u00a0or\u00a0medication. Labels, while they can be stigmatizing, can also lead those who bear them down the road to proper treatment and (hopefully) recovery. If one believes that \"being mentally ill\" is more than just believing one should fulfill a set of\u00a0diagnostic criteria, then one would probably also agree that there are some who are labeled \"mentally ill\" who need help. It has been claimed that this could not happen if there were no way to categorize (and therefore label) them, although there are actually plenty of\u00a0approaches\u00a0to these phenomena that don't use categorical classifications and diagnostic terms, such as spectrum\u00a0or continuum models. Here, people vary along different dimensions, and everyone falls at different points on each dimension.\r\n\r\nThe issue at stake is that\u00a0DSM-5\u00a0may lead to the increasingly widespread \u201cmedicalization\u201d of psychology. It is suggested that \u2013 also due to its impact via the social media \u2013\u00a0DSM-5\u00a0is likely to turn into a true \u201csocial representation\u201d (Moscovici et al., 2001) with the power to strongly influence clinical practice, pushing it in the direction of the large-scale prescription of drugs.[footnote]Castiglioni, M., &amp; Laudisa, F. (2015). Toward psychiatry as a 'human' science of mind. The case of depressive disorders in DSM-5. Frontiers in psychology, 5, 1517. https:\/\/doi.org\/10.3389\/fpsyg.2014.01517[\/footnote]\u00a0Allen Frances, Chair of the DSM-IV Task Force, came to be a remarkably prolific and vocal critic of the proposed changes that came out in the DSM-5. In a BMJ editorial, he described the \u2018grave\u2019 consequences of \u2018false positive epidemics\u2019 of disorders that would be constituted through inappropriate usage of new diagnostic entities; in so doing, DSM-5 would \u2018expand the territory of mental disorder and thin the ranks of the normal\u2019. In other words, it would help to further \u2018medicalize\u2019 society.[footnote]Pickersgill, MD (2014). Debating DSM-5: diagnosis and the sociology of critique. <em>Journal of Medical Ethics.<\/em>\u00a040:521-525.[\/footnote]\r\n<div class=\"textbox tryit\">\r\n<h3>Try It<\/h3>\r\nhttps:\/\/assess.lumenlearning.com\/practice\/d7ed6125-e319-472d-aa65-17257e5b24ee\r\n\r\n<\/div>\r\n<div class=\"textbox learning-objectives\">\r\n<h3>Glossary<\/h3>\r\n<div>\r\n\r\n<b>axis:<\/b>\u00a0a category of information regarding one dimension of an individual's functioning\r\n\r\n<span class=\"keyTerm ls2\"><b>categorical approach:<\/b><\/span>\u00a0attempts to categorize mental disorders into distinct diagnoses\r\n\r\n<strong>diagnostic reliability:\u00a0<\/strong>the degree to which different diagnosticians agree on a diagnosis;\u00a0consistency and reproducibility of a given result\r\n\r\n<strong>diagnostic\u00a0validity:<\/strong>\u00a0concerns\u00a0whether\u00a0the\u00a0diagnosis\u00a0measures\u00a0what\u00a0it\u00a0claims\u00a0to measure\r\n\r\n<span style=\"font-size: 1rem; text-align: initial;\"><strong>dimension:<\/strong> refers to a continuum on which an individual can have various levels of a characteristic<\/span>\r\n\r\n<strong>inter-rater<\/strong> <strong>reliability:<\/strong>\u00a0the degree of agreement among raters\r\n\r\n<span class=\"keyTerm ls2\"><b>labeling:<\/b><\/span>\u00a0occurs when information about a person's diagnostic classification is communicated in a negative manner that leads to stigma for the individual with a mental disorder.\r\n\r\n<b>multiaxial system:<\/b>\u00a0was intended to allow professionals to characterize clients in a multidimensional way (medical, psychological, developmental, and environmental\/social status)\r\n\r\n<\/div>\r\n<\/div>","rendered":"<div class=\"textbox learning-objectives\">\n<h3>Learning Objectives<\/h3>\n<ul>\n<li>Discuss arguments and objections surrounding the <em>DSM<\/em> classification system<\/li>\n<li>Describe problems associated with classification and labeling<\/li>\n<\/ul>\n<\/div>\n<h2 class=\"ls\">Advantages and Disadvantages of the\u00a0DSM\u20105 Classification System<\/h2>\n<p>With any system of classification like\u00a0<em>DSM\u20105<\/em>, there will always be strengths and weaknesses. One of the major strengths of the\u00a0<em>DSM<\/em>\u00a0system is the wide acceptance and use of the system. Mental health professionals in the United States routinely utilize\u00a0<span style=\"font-size: 1em;\">diagnostic systems\u00a0<\/span><span style=\"font-size: 1rem; text-align: initial;\">in their work\u00a0<\/span><span style=\"font-size: 1em; text-align: initial;\">if for no other reason than to allow their clients to receive treatment in hospitals and reimbursement from health care providers.\u00a0<\/span>Each category of disorder has a numeric code taken from the\u00a0<em>ICD<\/em> coding system, used for health service (including insurance) administrative purposes.<\/p>\n<p>The limitations of the\u00a0<em>DSM<\/em>\u00a0system are reflected in the terminology related to diagnosis itself. Since the DSM-3,\u00a0the goal was to improve the uniformity and validity of psychiatric diagnosis in the wake of a number of critiques, including the famous\u00a0<strong>Rosenhan experiment <\/strong>(see box below). There was also felt a need to standardize diagnostic practices within the United States and with other countries, after research showed that psychiatric diagnoses differed between Europe and the United States.<a class=\"footnote\" title=\"Cooper, JE; Kendell, RE; Gurland, BJ; Sartorius, N; Farkas, T (April 1969). &quot;Cross-national study of diagnosis of the mental disorders: some results from the first comparative investigation&quot;. The American Journal of Psychiatry. 125 (10 Suppl): 21\u20139. doi:10.1176\/ajp.125.10s.21. PMID 5774702. Archived from the original on 2010-08-24.\" id=\"return-footnote-1263-1\" href=\"#footnote-1263-1\" aria-label=\"Footnote 1\"><sup class=\"footnote\">[1]<\/sup><\/a><\/p>\n<div class=\"textbox exercises\">\n<h3>A closer look: The Rosenhan Experiment<\/h3>\n<p>The Rosenhan experiment was carried out by\u00a0David Rosenhan,\u00a0a Stanford University professor, and published by the journal\u00a0<em>Science<\/em>\u00a0in 1973 under the title\u00a0\u201cOn Being Sane in Insane Places.&#8221;<span style=\"font-size: 1rem; text-align: initial;\">\u00a0It was an experiment conducted to determine the reliability and validity of\u00a0psychiatric\u00a0diagnosis. The experimenters feigned hallucinations to enter psychiatric hospitals, and acted normally afterwards. They were diagnosed with psychiatric disorders and were given\u00a0antipsychotic\u00a0drugs. <\/span><\/p>\n<p><span style=\"font-size: 1rem; text-align: initial;\">The study was c<\/span><span style=\"text-align: initial;\"><span style=\"font-size: 1rem;\">onsidered an important and influential criticism of psychiatric diagnosis.\u00a0It has been argued that the experiment was fabricated;\u00a0<\/span>nonetheless<span style=\"font-size: 1rem;\">, the study concluded, \u201cit is clear that we cannot distinguish the sane from the insane in psychiatric hospitals,\u201d and it also illustrated the dangers of\u00a0dehumanization\u00a0and labeling in psychiatric institutions. It suggested that the use of community mental health facilities that concentrated on specific problems and behaviors rather than psychiatric labels might be a solution, and recommended education to make psychiatric workers more aware of the social psychology of their facilities.<\/span><\/span><\/p>\n<p><a href=\"https:\/\/www.youtube.com\/watch?v=D8OxdGV_7lo&amp;feature=emb_logo\" target=\"_blank\" rel=\"noopener\">Here is a seven-minute video summing up the study<\/a>.<\/p>\n<\/div>\n<h2>Reliability and Validity<\/h2>\n<p>The revisions and refinements in the <em>DSM<\/em> classification system have been largely driven by the need to improve reliability and validity. <strong>Reliability<\/strong> measures how consistent a diagnosis is and how reliably the categories can be judged. <strong>Validity<\/strong> looks at how accurate the diagnosis is and how valid the categories are in the sense of discriminating among disorders that have distinctive etiologies and possibly require different treatments.<\/p>\n<div class=\"textbox exercises\">\n<h3>Reliability Vs. Validity<\/h3>\n<p><iframe loading=\"lazy\" class=\"resizable\" src=\"https:\/\/lumenlearning.h5p.com\/content\/1290477372809028568\/embed\" frameborder=\"0\" width=\"500\" height=\"750\"><\/iframe><\/p>\n<\/div>\n<p>To be useful, any diagnostic system must demonstrate\u00a0<strong>reliability<\/strong>\u00a0and\u00a0<strong>validity<\/strong>. The revisions of the <em>DSM<\/em> from the third edition forward have been mainly concerned with\u00a0<strong>diagnostic reliability<\/strong>\u2014the degree to which different diagnosticians agree on a diagnosis.\u00a0If clinicians and researchers frequently disagree about the diagnosis of a patient, then research into the causes and effective treatments of those disorders cannot advance. To\u00a0be considered reliable, or consistent, different evaluators using the system should arrive at the same diagnoses when they evaluate the same people.<span style=\"font-size: 1rem; text-align: initial;\">\u00a0<\/span><span style=\"font-size: 1em;\">For example, a diagnosis of\u00a0<\/span><span style=\"font-size: 1em;\">major depressive disorder<\/span><span style=\"font-size: 1em;\">, a common mental illness, had a poor reliability\u00a0<\/span><span style=\"font-size: 1em;\">kappa<\/span><span style=\"font-size: 1em;\">\u00a0statistic of 0.28, indicating that clinicians frequently disagreed on diagnosing this disorder in the same patients. The most reliable diagnosis was major neurocognitive disorder, with a kappa of 0.78.<a class=\"footnote\" title=\"Freedman, Robert; Lewis, David A.; Michels, Robert; Pine, Daniel S.; Schultz, Susan K.; Tamminga, Carol A.; Gabbard, Glen O.; Gau, Susan Shur-Fen; Javitt, Daniel C.; Oquendo, Maria A.; Shrout, Patrick E.; Vieta, Eduard; Yager, Joel (January 2013). &quot;The Initial Field Trials of DSM-5: New Blooms and Old Thorns.&quot;\u00a0American Journal of Psychiatry. 170 (1): 1\u20135. doi:10.1176\/appi.ajp.2012.12091189. PMID 23288382. Archived from the original on 2013-01-15.\" id=\"return-footnote-1263-2\" href=\"#footnote-1263-2\" aria-label=\"Footnote 2\"><sup class=\"footnote\">[2]<\/sup><\/a><\/span><sup id=\"cite_ref-61\" class=\"reference\"><\/sup><\/p>\n<p>Critics assert, for example, that many <em>DSM-5<\/em> revisions or additions lack empirical support;\u00a0<strong>inter-rater<\/strong> <strong>reliability, <\/strong>or\u00a0the degree of agreement among raters,\u00a0is low for many disorders; several sections contain poorly written, confusing, or contradictory information; and the psychiatric drug industry unduly influenced the manual&#8217;s content (many <em>DSM-5<\/em> workgroup participants had ties to pharmaceutical companies).<sup id=\"cite_ref-2\" class=\"reference\"><\/sup>footnote]Welch, Steven; Klassen, Cherisse; Borisova, Oxana; Clothier, Holly (2013). &#8220;The <em>DSM-5<\/em> controversies: How should psychologists respond?&#8221;. Canadian Psychology. 54(3): 166\u2013175. doi:10.1037\/a0033841[\/footnote]<\/p>\n<p><strong>Diagnostic\u00a0validity<\/strong>\u00a0concerns\u00a0whether\u00a0the\u00a0diagnosis\u00a0measures\u00a0what\u00a0it\u00a0claims\u00a0to\u00a0measure. In psychiatry, there\u00a0is a particular issue with assessing the validity of the\u00a0diagnostic categories\u00a0themselves. In this context,<\/p>\n<ul>\n<li><strong>content validity<\/strong> may refer to symptoms and diagnostic criteria.<\/li>\n<li><strong>concurrent validity<\/strong>\u00a0looks at whether the markers that indicate a disorder actually correlate with the disorder, and if these markers are true over time and across multiple people and measures. It may also look at the appropriate alignment of a treatment response to a disorder.<\/li>\n<li><strong>predictive validity<\/strong> may refer mainly to diagnostic stability over time and\u00a0the relationship between the diagnosis and the ability to predict people\u2019s behavior in certain situations.<\/li>\n<li><strong>discriminant validity<\/strong> may involve delimitation from other disorders.<\/li>\n<\/ul>\n<p>Robins and Guze proposed in 1970 what were to become influential formal criteria for establishing the validity of psychiatric diagnoses. The five phases of diagnostic validation used by Robins and Guze were (1) clinical characteristics of the syndrome and of the patients who develop it (including core symptoms, demographic characteristics, and precipitating factors); (2) exclusionary criteria differentiating the syndrome from other known disorders; (3) family studies; (4) laboratory data (radiological, chemical, pathologic, and psychological evidence); and (5) follow-up studies (for diagnostic stability, course, and treatment response).<a class=\"footnote\" title=\"Sur\u00eds, A., Holliday, R., &amp; North, C. S. (2016). The Evolution of the Classification of Psychiatric Disorders. Behavioral sciences (Basel, Switzerland), 6(1), 5. https:\/\/doi.org\/10.3390\/bs6010005\" id=\"return-footnote-1263-3\" href=\"#footnote-1263-3\" aria-label=\"Footnote 3\"><sup class=\"footnote\">[3]<\/sup><\/a> Once the characteristics of disorder, the exclusionary criteria, family, lab, and follow-up studies are completed, there should be enough information to deem the <em>DSM<\/em> content as a valid description of the mental disorder.<\/p>\n<div id=\"attachment_4707\" style=\"width: 292px\" class=\"wp-caption alignright\"><img loading=\"lazy\" decoding=\"async\" aria-describedby=\"caption-attachment-4707\" class=\"wp-image-4707\" src=\"https:\/\/s3-us-west-2.amazonaws.com\/courses-images\/wp-content\/uploads\/sites\/5351\/2020\/08\/24043156\/hospital-3098683_1920-300x200.jpg\" alt=\"A room in a hospital where MRI (magnetic resonance imaging) is being performed.\" width=\"282\" height=\"188\" \/><\/p>\n<p id=\"caption-attachment-4707\" class=\"wp-caption-text\"><strong>Figure 1.<\/strong> Radiology laboratory studies like MRIs are included in the criteria for validity.<\/p>\n<\/div>\n<p>These were incorporated into the\u00a0Feighner Criteria\u00a0and\u00a0Research Diagnostic Criteria\u00a0that have since formed the basis of the <em>DSM<\/em> and <em>ICD<\/em> classification systems.\u00a0<a class=\"footnote\" title=\"Kendell, R; Jablensky, A (2003). &quot;Distinguishing between the validity and utility of psychiatric diagnoses&quot;. The American Journal of Psychiatry. 160 (1): 4\u201312. doi:10.1176\/appi.ajp.160.1.4. PMID 12505793\" id=\"return-footnote-1263-4\" href=\"#footnote-1263-4\" aria-label=\"Footnote 4\"><sup class=\"footnote\">[4]<\/sup><\/a><\/p>\n<p>Other critics also believe the\u00a0<em>DSM<\/em>\u00a0needs to become more sensitive to the importance of cultural and ethnic factors in diagnostic assessment.\u00a0They encourage us to consider and understand that the symptoms or problem behaviors included as diagnostic criteria in the\u00a0<em>DSM<\/em>\u00a0were largely determined by a consensus of mostly U.S.-trained psychiatrists, psychologists, and social workers. Imagine that the American Psychiatric Association had asked Asian-trained or Latin American\u2013trained professionals to develop their diagnostic manual? Might there might have been different diagnostic criteria or even different diagnostic categories? <a class=\"footnote\" title=\"Alarc\u00f3n, R. D., Becker, A. E., Lewis-Fern\u00e1ndez, R., Like, R. C., Desai, P., Foulks, E.,\u2009.\u2009.\u2009.\u2009Primm, A. (2009). Issues for DSM-5: The role of culture in psychiatric diagnosis. The Journal of Nervous and Mental Disease, 197, 559\u2013660. doi:10.1097\/NMD.0b013e3181b0cbff\" id=\"return-footnote-1263-5\" href=\"#footnote-1263-5\" aria-label=\"Footnote 5\"><sup class=\"footnote\">[5]<\/sup><\/a><\/p>\n<p><span style=\"font-size: 1em;\">Overall, the bulk of limitations of the\u00a0<em>DSM<\/em>\u00a0system listed so far are related to the diagnostic system in general.\u00a0It is worthwhile to be alert to the criticisms of the <em>DSM<\/em> system, particularly since they serve as a reminder that mental health professionals aim to help\u00a0<span style=\"font-size: 1em;\">the individual\u00a0<\/span><span style=\"font-size: 1em;\">and not the disorder. Furthermore, t<\/span>he\u00a0<em>DSM<\/em>\u00a0system has been useful to\u00a0<\/span><span style=\"font-size: 1em;\">insurance companies who adopt its use to establish coverage for certain clinical disorders, and has been\u00a0<\/span><span style=\"font-size: 1rem; text-align: initial;\">helpful in allowing researchers and clinicians to have a common language with which to discuss clients.\u00a0<\/span><\/p>\n<div class=\"textbox tryit\">\n<h3>Try It<\/h3>\n<p>\t<iframe id=\"assessment_practice_39ff7e80-39e4-4821-ad0c-4cd6045fc4b4\" class=\"resizable\" src=\"https:\/\/assess.lumenlearning.com\/practice\/39ff7e80-39e4-4821-ad0c-4cd6045fc4b4?iframe_resize_id=assessment_practice_id_39ff7e80-39e4-4821-ad0c-4cd6045fc4b4\" frameborder=\"0\" style=\"border:none;width:100%;height:100%;min-height:300px;\"><br \/>\n\t<\/iframe><\/p>\n<p>\t<iframe id=\"assessment_practice_27c70fbb-9564-4a61-80a3-cd44ab449522\" class=\"resizable\" src=\"https:\/\/assess.lumenlearning.com\/practice\/27c70fbb-9564-4a61-80a3-cd44ab449522?iframe_resize_id=assessment_practice_id_27c70fbb-9564-4a61-80a3-cd44ab449522\" frameborder=\"0\" style=\"border:none;width:100%;height:100%;min-height:300px;\"><br \/>\n\t<\/iframe><\/p>\n<\/div>\n<h2>Differences between Categorical and Dimensional Understanding of Behavior<\/h2>\n<p>Both the\u00a0<em>DSM<\/em>\u00a0and\u00a0<em>ICD<\/em>\u00a0systems represent a\u00a0<span class=\"keyTerm ls2\"><b>categorical approach<\/b><\/span>\u00a0to the description of mental disorders. As the name implies, a categorical approach attempts to categorize mental disorders into distinct diagnoses. The categorical approach is based on the idea that a person either meets criteria for a specific disorder or they do not.\u00a0<span style=\"font-size: 1em;\">Traditional categorical models of classification, which are based on the\u00a0<\/span><span style=\"font-size: 1em;\">presence or absence of\u00a0<\/span><span style=\"font-size: 1em;\">symptoms,\u00a0<\/span><span style=\"font-size: 1em;\">do not take into account levels of expression of a characteristic or the presence of any underlying <strong>dimension<\/strong>.\u00a0<\/span><span style=\"text-align: initial;\"><span style=\"font-size: 1rem;\">This conceptualization allows a mental <\/span>health<span style=\"font-size: 1rem;\">\u00a0professional to make a dichotomous decision (i.e., yes, the person meets criteria or no, the person does not meet criteria for that disorder). A<\/span><\/span><span style=\"font-size: 1rem; text-align: initial;\">\u00a0<em>dimension<\/em>\u00a0refers to a continuum on which an individual can have various levels of a characteristic, in contrast to the\u00a0<\/span><span style=\"font-size: 1rem; text-align: initial;\">dichotomous<\/span><span style=\"font-size: 1rem; text-align: initial;\">\u00a0categorical approach in which an individual does or does not possess a characteristic<\/span><span style=\"font-size: 1rem; text-align: initial;\">.\u00a0<\/span><\/p>\n<p>The\u00a0<em>DSM-4<\/em> organized diagnoses using five separate axes (clinical disorders, personality disorders, general medical disorders, and then sections on psychosocial and environmental factors, and the global assessment of functioning (which measured the severity of a disorder). An\u00a0<b>axis<\/b>\u00a0is defined as a category of information regarding one dimension of an individual&#8217;s functioning. In the <em>DSM-IV-TR<\/em> system, an individual was diagnosed on five different domains, or &#8220;axes.&#8221; The <em>DSM-5<\/em> got rid of the axis system, as there was no scientific justification for grouping things by axis. Originally, the\u00a0<b>multiaxial system<\/b>\u00a0was intended to allow professionals to characterize clients in a multidimensional way (medical, psychological, developmental, and environmental\/social status), but rationale for removal of the multi-axial system was based on unclear boundaries between medical and psychiatric diagnoses, inconsistent use of Axis IV by clinicians and researchers (psychosocial and environmental problems), and poor psychometric and clinical validity of Axis V (Global Assessment of Functioning).<a class=\"footnote\" title=\"Sur\u00eds, A.; Holliday, R.; North, C.S. The Evolution of the Classification of Psychiatric Disorders.\u00a0Behav. Sci.\u00a02016,\u00a06, 5.\" id=\"return-footnote-1263-6\" href=\"#footnote-1263-6\" aria-label=\"Footnote 6\"><sup class=\"footnote\">[6]<\/sup><\/a><\/p>\n<p>The most important change in <em>DSM-5<\/em> was the inclusion of dimensions in diagnoses; for example, how severely ill is a patient with schizophrenia or depression? The dimensional approach focuses on\u00a0<span style=\"font-size: 1em;\">varying levels of different behaviors that a person exhibits, r<\/span><span style=\"font-size: 1rem; text-align: initial;\">ather than whether or not a person meets criteria for a particular disorder.\u00a0<\/span><span style=\"font-size: 1rem; text-align: initial;\">T<\/span>he <strong>dimensional approach<\/strong> is also included in Section III (&#8220;Emerging Measures and Models&#8221;). This section<span style=\"font-size: 1em;\">\u00a0includes assessment measures and diagnoses not considered well-established enough to be part of the main system. For example,\u00a0<\/span>an &#8220;Alternative DSM-5 Model for Personality Disorders&#8221; is described.<a class=\"footnote\" title=\"American Psychiatric Association (2013). Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. World Psychiatry. 14. pp. 234\u2013236.\" id=\"return-footnote-1263-7\" href=\"#footnote-1263-7\" aria-label=\"Footnote 7\"><sup class=\"footnote\">[7]<\/sup><\/a>\u00a0The decision to retain the old <em>DSM-4<\/em> categorical model for personality disorders in <em>DSM-5<\/em> was controversial (currently the ten personality disorders are grouped into three general categories), and efforts continue to persuade the\u00a0American Psychiatric Association\u00a0to replace it with the dimensional model in <em>DSM 5.1.\u00a0<\/em><a class=\"footnote\" title=\"Skodol, Andrew E.; Leslie C. Morey; Donna S. Bender; John M. Oldham (2013). &quot;The ironic fate of the personality disorders in DSM-5.&quot; Personality Disorders: Theory, Research, and Treatment. 4 (4): 342\u2013349.\" id=\"return-footnote-1263-8\" href=\"#footnote-1263-8\" aria-label=\"Footnote 8\"><sup class=\"footnote\">[8]<\/sup><\/a><sup id=\"cite_ref-3\" class=\"reference\"><\/sup><\/p>\n<p>Since the categorical model is widely used in clinical practice and has a significant body of research supporting it, its common usage is compelling to laypeople when they are judging the credibility of professional opinion. Therefore, the dimensional approach is often further criticized for being difficult to interpret and less accessible. It is, however, widely used in some professional settings as the established approach, for example by\u00a0forensic psychologists.\u00a0<a class=\"footnote\" title=\"Weiner, Irving B. (2003). Handbook of Psychology, Volume 11, Forensic Psychology. 11. Hoboken, NJ: Wiley. pp. 120\u2013121.\" id=\"return-footnote-1263-9\" href=\"#footnote-1263-9\" aria-label=\"Footnote 9\"><sup class=\"footnote\">[9]<\/sup><\/a><sup id=\"cite_ref-Weiner11_11-0\" class=\"reference\"><\/sup><\/p>\n<p>Regardless of whether you use a categorical or dimensional approach to understand a person&#8217;s functioning, it is crucial to remember that behavior can change over time.<\/p>\n<h2>Problems Associated with Classification and Labeling<\/h2>\n<p>Finally, but probably most importantly, any diagnostic system such as the\u00a0DSM\u00a0system allows for individuals to be labeled for behavior that may or may not be an important part of their character.\u00a0<span class=\"keyTerm ls2\"><b>Labeling<\/b><\/span>\u00a0occurs when information about a person&#8217;s diagnostic classification is communicated in a negative manner that leads to stigma for the individual with a mental disorder.<\/p>\n<h2><span id=\"The_&quot;mentally_ill&quot;\" class=\"mw-headline\">The &#8220;Mentally Ill&#8221;<\/span><\/h2>\n<p>The social construction of\u00a0deviant behavior\u00a0plays an important role in the labeling process that occurs in society. This process involves not only the labeling of criminally deviant behavior, which is behavior that does not fit socially constructed norms, but also labeling that which reflects stereotyped or stigmatized behavior of the &#8220;mentally ill.&#8221; The <strong>labeling theory<\/strong> was first applied to the term <em>&#8220;<\/em>mentally ill&#8221; in 1966 when\u00a0Thomas J. Scheff\u00a0published\u00a0<i>Being Mentally Ill<\/i>. Scheff challenged common perceptions of\u00a0mental disorders\u00a0by claiming that mental disorder is manifested solely as a result of societal influence. Scheff argued that society views certain behaviors and actions as\u00a0deviant\u00a0and, in order to come to terms with and understand these actions, often places the label of mental disorder on those who exhibit them. Certain expectations are then placed on these individuals and, over time, they unconsciously change their behavior to fulfill them. Criteria for different mental illnesses are not consistently fulfilled by those who are diagnosed with them because all of these people suffer from the same disorder, they are simply fulfilled because the <em>&#8220;mentally ill&#8221;<\/em> believe they are supposed to act a certain way so, over time, come to do so.<a class=\"footnote\" title=\"Scheff, Thomas J. 1984. Being Mentally Ill (2nd ed.). Piscataway: Aldine Transaction.\" id=\"return-footnote-1263-10\" href=\"#footnote-1263-10\" aria-label=\"Footnote 10\"><sup class=\"footnote\">[10]<\/sup><\/a><\/p>\n<p>Scheff&#8217;s theory had many critics, most notably\u00a0Walter Gove\u00a0who consistently argued against Scheff with an almost opposite theory; he believed that society has no influence at all on mental disorder. Instead, any societal perceptions of the <em>&#8220;mentally ill&#8221;<\/em> come about as a direct result of these people&#8217;s behaviors. Most sociologists&#8217; views of labeling and mental disorder have fallen somewhere between the extremes of Gove and Scheff. On the other hand, it is almost impossible to deny, given both common sense and research findings, that society&#8217;s negative perceptions of &#8220;crazy&#8221; people has had some effect on them. It seems that, realistically, labeling can accentuate and prolong the issues termed &#8220;mental illness&#8221;, but it is rarely the full cause.<a class=\"footnote\" title=\"Gove, Walter R. (1975). Labelling of Deviance: Evaluating a Perspective. Hoboken: John Wiley &amp; Sons Inc.\" id=\"return-footnote-1263-11\" href=\"#footnote-1263-11\" aria-label=\"Footnote 11\"><sup class=\"footnote\">[11]<\/sup><\/a><\/p>\n<p><b>Labeling theory<\/b>\u00a0posits that\u00a0self-identity\u00a0and the behavior of individuals may be determined or influenced by the terms used to describe or classify them. It is associated with the concepts of\u00a0<strong>self-fulfilling prophecy<\/strong>\u00a0and\u00a0<strong>stereotyping<\/strong>.\u00a0However, the label of<em> &#8220;<\/em>mentally ill<em>&#8220;<\/em> may help a person seek help, for example, psychotherapy\u00a0or\u00a0medication. Labels, while they can be stigmatizing, can also lead those who bear them down the road to proper treatment and (hopefully) recovery. If one believes that &#8220;being mentally ill&#8221; is more than just believing one should fulfill a set of\u00a0diagnostic criteria, then one would probably also agree that there are some who are labeled &#8220;mentally ill&#8221; who need help. It has been claimed that this could not happen if there were no way to categorize (and therefore label) them, although there are actually plenty of\u00a0approaches\u00a0to these phenomena that don&#8217;t use categorical classifications and diagnostic terms, such as spectrum\u00a0or continuum models. Here, people vary along different dimensions, and everyone falls at different points on each dimension.<\/p>\n<p>The issue at stake is that\u00a0DSM-5\u00a0may lead to the increasingly widespread \u201cmedicalization\u201d of psychology. It is suggested that \u2013 also due to its impact via the social media \u2013\u00a0DSM-5\u00a0is likely to turn into a true \u201csocial representation\u201d (Moscovici et al., 2001) with the power to strongly influence clinical practice, pushing it in the direction of the large-scale prescription of drugs.<a class=\"footnote\" title=\"Castiglioni, M., &amp; Laudisa, F. (2015). Toward psychiatry as a 'human' science of mind. The case of depressive disorders in DSM-5. Frontiers in psychology, 5, 1517. https:\/\/doi.org\/10.3389\/fpsyg.2014.01517\" id=\"return-footnote-1263-12\" href=\"#footnote-1263-12\" aria-label=\"Footnote 12\"><sup class=\"footnote\">[12]<\/sup><\/a>\u00a0Allen Frances, Chair of the DSM-IV Task Force, came to be a remarkably prolific and vocal critic of the proposed changes that came out in the DSM-5. In a BMJ editorial, he described the \u2018grave\u2019 consequences of \u2018false positive epidemics\u2019 of disorders that would be constituted through inappropriate usage of new diagnostic entities; in so doing, DSM-5 would \u2018expand the territory of mental disorder and thin the ranks of the normal\u2019. In other words, it would help to further \u2018medicalize\u2019 society.<a class=\"footnote\" title=\"Pickersgill, MD (2014). Debating DSM-5: diagnosis and the sociology of critique. Journal of Medical Ethics.\u00a040:521-525.\" id=\"return-footnote-1263-13\" href=\"#footnote-1263-13\" aria-label=\"Footnote 13\"><sup class=\"footnote\">[13]<\/sup><\/a><\/p>\n<div class=\"textbox tryit\">\n<h3>Try It<\/h3>\n<p>\t<iframe id=\"assessment_practice_d7ed6125-e319-472d-aa65-17257e5b24ee\" class=\"resizable\" src=\"https:\/\/assess.lumenlearning.com\/practice\/d7ed6125-e319-472d-aa65-17257e5b24ee?iframe_resize_id=assessment_practice_id_d7ed6125-e319-472d-aa65-17257e5b24ee\" frameborder=\"0\" style=\"border:none;width:100%;height:100%;min-height:300px;\"><br \/>\n\t<\/iframe><\/p>\n<\/div>\n<div class=\"textbox learning-objectives\">\n<h3>Glossary<\/h3>\n<div>\n<p><b>axis:<\/b>\u00a0a category of information regarding one dimension of an individual&#8217;s functioning<\/p>\n<p><span class=\"keyTerm ls2\"><b>categorical approach:<\/b><\/span>\u00a0attempts to categorize mental disorders into distinct diagnoses<\/p>\n<p><strong>diagnostic reliability:\u00a0<\/strong>the degree to which different diagnosticians agree on a diagnosis;\u00a0consistency and reproducibility of a given result<\/p>\n<p><strong>diagnostic\u00a0validity:<\/strong>\u00a0concerns\u00a0whether\u00a0the\u00a0diagnosis\u00a0measures\u00a0what\u00a0it\u00a0claims\u00a0to measure<\/p>\n<p><span style=\"font-size: 1rem; text-align: initial;\"><strong>dimension:<\/strong> refers to a continuum on which an individual can have various levels of a characteristic<\/span><\/p>\n<p><strong>inter-rater<\/strong> <strong>reliability:<\/strong>\u00a0the degree of agreement among raters<\/p>\n<p><span class=\"keyTerm ls2\"><b>labeling:<\/b><\/span>\u00a0occurs when information about a person&#8217;s diagnostic classification is communicated in a negative manner that leads to stigma for the individual with a mental disorder.<\/p>\n<p><b>multiaxial system:<\/b>\u00a0was intended to allow professionals to characterize clients in a multidimensional way (medical, psychological, developmental, and environmental\/social status)<\/p>\n<\/div>\n<\/div>\n\n\t\t\t <section class=\"citations-section\" role=\"contentinfo\">\n\t\t\t <h3>Candela Citations<\/h3>\n\t\t\t\t\t <div>\n\t\t\t\t\t\t <div id=\"citation-list-1263\">\n\t\t\t\t\t\t\t <div class=\"licensing\"><div class=\"license-attribution-dropdown-subheading\">CC licensed content, Shared previously<\/div><ul class=\"citation-list\"><li>MRI. <strong>Authored by<\/strong>: Bokskapet. <strong>Located at<\/strong>: <a target=\"_blank\" href=\"https:\/\/pixabay.com\/photos\/hospital-equipment-medicine-patient-3098683\/\">https:\/\/pixabay.com\/photos\/hospital-equipment-medicine-patient-3098683\/<\/a>. <strong>License<\/strong>: <em>Other<\/em>. <strong>License Terms<\/strong>: Pixabay License<\/li><li>Diagnostic and Statistical Manual of Mental Disorders. <strong>Provided by<\/strong>: Wikipedia. <strong>Located at<\/strong>: <a target=\"_blank\" href=\"https:\/\/en.wikipedia.org\/wiki\/Diagnostic_and_Statistical_Manual_of_Mental_Disorders#Categorization\">https:\/\/en.wikipedia.org\/wiki\/Diagnostic_and_Statistical_Manual_of_Mental_Disorders#Categorization<\/a>. <strong>License<\/strong>: <em><a target=\"_blank\" rel=\"license\" href=\"https:\/\/creativecommons.org\/about\/pdm\">Public Domain: No Known Copyright<\/a><\/em><\/li><li>Rosenhan Experiment. <strong>Provided by<\/strong>: Wikipedia. <strong>Located at<\/strong>: <a target=\"_blank\" href=\"https:\/\/en.wikipedia.org\/wiki\/Rosenhan_experiment\">https:\/\/en.wikipedia.org\/wiki\/Rosenhan_experiment<\/a>. <strong>License<\/strong>: <em><a target=\"_blank\" rel=\"license\" href=\"https:\/\/creativecommons.org\/licenses\/by-sa\/4.0\/\">CC BY-SA: Attribution-ShareAlike<\/a><\/em><\/li><li>Textbook of Psychiatry: Diagnosis and Classification. <strong>Provided by<\/strong>: Wikibooks. <strong>Located at<\/strong>: <a target=\"_blank\" href=\"https:\/\/en.wikibooks.org\/wiki\/Textbook_of_Psychiatry\/Print_version#Diagnosis_&#038;_Classification\">https:\/\/en.wikibooks.org\/wiki\/Textbook_of_Psychiatry\/Print_version#Diagnosis_&#038;_Classification<\/a>. <strong>License<\/strong>: <em><a target=\"_blank\" rel=\"license\" href=\"https:\/\/creativecommons.org\/licenses\/by-sa\/4.0\/\">CC BY-SA: Attribution-ShareAlike<\/a><\/em><\/li><li>Labeling theory. <strong>Provided by<\/strong>: Wikipedia. <strong>Located at<\/strong>: <a target=\"_blank\" href=\"https:\/\/en.wikipedia.org\/wiki\/Labeling_theory#cite_note-Scheff1-20\">https:\/\/en.wikipedia.org\/wiki\/Labeling_theory#cite_note-Scheff1-20<\/a>. <strong>License<\/strong>: <em><a target=\"_blank\" rel=\"license\" href=\"https:\/\/creativecommons.org\/licenses\/by-sa\/4.0\/\">CC BY-SA: Attribution-ShareAlike<\/a><\/em><\/li><li>Dimensional models of personality disorders. <strong>Provided by<\/strong>: Wikipedia. <strong>Located at<\/strong>: <a target=\"_blank\" href=\"https:\/\/en.wikipedia.org\/wiki\/Dimensional_models_of_personality_disorders\">https:\/\/en.wikipedia.org\/wiki\/Dimensional_models_of_personality_disorders<\/a>. <strong>License<\/strong>: <em><a target=\"_blank\" rel=\"license\" href=\"https:\/\/creativecommons.org\/licenses\/by-sa\/4.0\/\">CC BY-SA: Attribution-ShareAlike<\/a><\/em><\/li><\/ul><\/div>\n\t\t\t\t\t\t <\/div>\n\t\t\t\t\t <\/div>\n\t\t\t <\/section><hr class=\"before-footnotes clear\" \/><div class=\"footnotes\"><ol><li id=\"footnote-1263-1\">Cooper, JE; Kendell, RE; Gurland, BJ; Sartorius, N; Farkas, T (April 1969). \"Cross-national study of diagnosis of the mental disorders: some results from the first comparative investigation\". <em>The American Journal of Psychiatry<\/em>. 125 (10 Suppl): 21\u20139. doi:10.1176\/ajp.125.10s.21. PMID 5774702. Archived from the original on 2010-08-24. <a href=\"#return-footnote-1263-1\" class=\"return-footnote\" aria-label=\"Return to footnote 1\">&crarr;<\/a><\/li><li id=\"footnote-1263-2\">Freedman, Robert; Lewis, David A.; Michels, Robert; Pine, Daniel S.; Schultz, Susan K.; Tamminga, Carol A.; Gabbard, Glen O.; Gau, Susan Shur-Fen; Javitt, Daniel C.; Oquendo, Maria A.; Shrout, Patrick E.; Vieta, Eduard; Yager, Joel (January 2013). \"The Initial Field Trials of <em>DSM-5<\/em>: New Blooms and Old Thorns.\"\u00a0<em>American Journal of Psychiatry<\/em>. 170 (1): 1\u20135. doi:10.1176\/appi.ajp.2012.12091189. PMID 23288382. Archived from the original on 2013-01-15. <a href=\"#return-footnote-1263-2\" class=\"return-footnote\" aria-label=\"Return to footnote 2\">&crarr;<\/a><\/li><li id=\"footnote-1263-3\">Sur\u00eds, A., Holliday, R., &amp; North, C. S. (2016). The Evolution of the Classification of Psychiatric Disorders. Behavioral sciences (Basel, Switzerland), 6(1), 5. https:\/\/doi.org\/10.3390\/bs6010005 <a href=\"#return-footnote-1263-3\" class=\"return-footnote\" aria-label=\"Return to footnote 3\">&crarr;<\/a><\/li><li id=\"footnote-1263-4\">Kendell, R; Jablensky, A (2003). \"Distinguishing between the validity and utility of psychiatric diagnoses\". The American Journal of Psychiatry. 160 (1): 4\u201312. doi:10.1176\/appi.ajp.160.1.4. PMID 12505793 <a href=\"#return-footnote-1263-4\" class=\"return-footnote\" aria-label=\"Return to footnote 4\">&crarr;<\/a><\/li><li id=\"footnote-1263-5\">Alarc\u00f3n, R. D., Becker, A. E., Lewis-Fern\u00e1ndez, R., Like, R. C., Desai, P., Foulks, E.,\u2009.\u2009.\u2009.\u2009Primm, A. (2009). Issues for <em>DSM-5<\/em>: The role of culture in psychiatric diagnosis. <em>The Journal of Nervous and Mental Disease<\/em>, 197, 559\u2013660. doi:10.1097\/NMD.0b013e3181b0cbff <a href=\"#return-footnote-1263-5\" class=\"return-footnote\" aria-label=\"Return to footnote 5\">&crarr;<\/a><\/li><li id=\"footnote-1263-6\">Sur\u00eds, A.; Holliday, R.; North, C.S. <em>The Evolution of the Classification of Psychiatric Disorders<\/em>.\u00a0<em>Behav. Sci.<\/em>\u00a02016,\u00a0<em>6<\/em>, 5. <a href=\"#return-footnote-1263-6\" class=\"return-footnote\" aria-label=\"Return to footnote 6\">&crarr;<\/a><\/li><li id=\"footnote-1263-7\">American Psychiatric Association (2013). <em>Diagnostic and Statistical Manual of Mental Disorders<\/em>, Fifth Edition. World Psychiatry. 14. pp. 234\u2013236. <a href=\"#return-footnote-1263-7\" class=\"return-footnote\" aria-label=\"Return to footnote 7\">&crarr;<\/a><\/li><li id=\"footnote-1263-8\">Skodol, Andrew E.; Leslie C. Morey; Donna S. Bender; John M. Oldham (2013). \"The ironic fate of the personality disorders in <em>DSM-5<\/em>.\" <em>Personality Disorders: Theory, Research, and Treatment<\/em>. 4 (4): 342\u2013349. <a href=\"#return-footnote-1263-8\" class=\"return-footnote\" aria-label=\"Return to footnote 8\">&crarr;<\/a><\/li><li id=\"footnote-1263-9\">Weiner, Irving B. (2003). Handbook of Psychology, Volume 11, Forensic Psychology. 11. Hoboken, NJ: Wiley. pp. 120\u2013121. <a href=\"#return-footnote-1263-9\" class=\"return-footnote\" aria-label=\"Return to footnote 9\">&crarr;<\/a><\/li><li id=\"footnote-1263-10\">Scheff, Thomas J. 1984. Being Mentally Ill (2nd ed.). Piscataway: Aldine Transaction. <a href=\"#return-footnote-1263-10\" class=\"return-footnote\" aria-label=\"Return to footnote 10\">&crarr;<\/a><\/li><li id=\"footnote-1263-11\">Gove, Walter R. (1975). Labelling of Deviance: Evaluating a Perspective. Hoboken: John Wiley &amp; Sons Inc. <a href=\"#return-footnote-1263-11\" class=\"return-footnote\" aria-label=\"Return to footnote 11\">&crarr;<\/a><\/li><li id=\"footnote-1263-12\">Castiglioni, M., &amp; Laudisa, F. (2015). Toward psychiatry as a 'human' science of mind. The case of depressive disorders in DSM-5. Frontiers in psychology, 5, 1517. https:\/\/doi.org\/10.3389\/fpsyg.2014.01517 <a href=\"#return-footnote-1263-12\" class=\"return-footnote\" aria-label=\"Return to footnote 12\">&crarr;<\/a><\/li><li id=\"footnote-1263-13\">Pickersgill, MD (2014). Debating DSM-5: diagnosis and the sociology of critique. <em>Journal of Medical Ethics.<\/em>\u00a040:521-525. <a href=\"#return-footnote-1263-13\" class=\"return-footnote\" aria-label=\"Return to footnote 13\">&crarr;<\/a><\/li><\/ol><\/div>","protected":false},"author":29,"menu_order":9,"template":"","meta":{"_candela_citation":"[{\"type\":\"cc\",\"description\":\"MRI\",\"author\":\"Bokskapet\",\"organization\":\"\",\"url\":\"https:\/\/pixabay.com\/photos\/hospital-equipment-medicine-patient-3098683\/\",\"project\":\"\",\"license\":\"other\",\"license_terms\":\"Pixabay License\"},{\"type\":\"cc\",\"description\":\"Diagnostic and Statistical Manual of Mental Disorders\",\"author\":\"\",\"organization\":\"Wikipedia\",\"url\":\"https:\/\/en.wikipedia.org\/wiki\/Diagnostic_and_Statistical_Manual_of_Mental_Disorders#Categorization\",\"project\":\"\",\"license\":\"pd\",\"license_terms\":\"\"},{\"type\":\"cc\",\"description\":\"Rosenhan Experiment\",\"author\":\"\",\"organization\":\"Wikipedia\",\"url\":\"https:\/\/en.wikipedia.org\/wiki\/Rosenhan_experiment\",\"project\":\"\",\"license\":\"cc-by-sa\",\"license_terms\":\"\"},{\"type\":\"cc\",\"description\":\"Textbook of Psychiatry: Diagnosis and Classification\",\"author\":\"\",\"organization\":\"Wikibooks\",\"url\":\"https:\/\/en.wikibooks.org\/wiki\/Textbook_of_Psychiatry\/Print_version#Diagnosis_&_Classification\",\"project\":\"\",\"license\":\"cc-by-sa\",\"license_terms\":\"\"},{\"type\":\"cc\",\"description\":\"Labeling theory\",\"author\":\"\",\"organization\":\"Wikipedia\",\"url\":\"https:\/\/en.wikipedia.org\/wiki\/Labeling_theory#cite_note-Scheff1-20\",\"project\":\"\",\"license\":\"cc-by-sa\",\"license_terms\":\"\"},{\"type\":\"cc\",\"description\":\"Dimensional models of personality disorders\",\"author\":\"\",\"organization\":\"Wikipedia\",\"url\":\"https:\/\/en.wikipedia.org\/wiki\/Dimensional_models_of_personality_disorders\",\"project\":\"\",\"license\":\"cc-by-sa\",\"license_terms\":\"\"}]","CANDELA_OUTCOMES_GUID":"8fc96ed1-1cca-453c-a4a6-a5e91e30c744, 261f9631-12be-4d24-ae29-0836286513f8, 9d9bf61a-fff7-49ce-98ba-4010dc9ad426","pb_show_title":"on","pb_short_title":"","pb_subtitle":"","pb_authors":[],"pb_section_license":""},"chapter-type":[],"contributor":[],"license":[],"class_list":["post-1263","chapter","type-chapter","status-publish","hentry"],"part":132,"_links":{"self":[{"href":"https:\/\/courses.lumenlearning.com\/wm-abnormalpsych\/wp-json\/pressbooks\/v2\/chapters\/1263","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/courses.lumenlearning.com\/wm-abnormalpsych\/wp-json\/pressbooks\/v2\/chapters"}],"about":[{"href":"https:\/\/courses.lumenlearning.com\/wm-abnormalpsych\/wp-json\/wp\/v2\/types\/chapter"}],"author":[{"embeddable":true,"href":"https:\/\/courses.lumenlearning.com\/wm-abnormalpsych\/wp-json\/wp\/v2\/users\/29"}],"version-history":[{"count":36,"href":"https:\/\/courses.lumenlearning.com\/wm-abnormalpsych\/wp-json\/pressbooks\/v2\/chapters\/1263\/revisions"}],"predecessor-version":[{"id":7559,"href":"https:\/\/courses.lumenlearning.com\/wm-abnormalpsych\/wp-json\/pressbooks\/v2\/chapters\/1263\/revisions\/7559"}],"part":[{"href":"https:\/\/courses.lumenlearning.com\/wm-abnormalpsych\/wp-json\/pressbooks\/v2\/parts\/132"}],"metadata":[{"href":"https:\/\/courses.lumenlearning.com\/wm-abnormalpsych\/wp-json\/pressbooks\/v2\/chapters\/1263\/metadata\/"}],"wp:attachment":[{"href":"https:\/\/courses.lumenlearning.com\/wm-abnormalpsych\/wp-json\/wp\/v2\/media?parent=1263"}],"wp:term":[{"taxonomy":"chapter-type","embeddable":true,"href":"https:\/\/courses.lumenlearning.com\/wm-abnormalpsych\/wp-json\/pressbooks\/v2\/chapter-type?post=1263"},{"taxonomy":"contributor","embeddable":true,"href":"https:\/\/courses.lumenlearning.com\/wm-abnormalpsych\/wp-json\/wp\/v2\/contributor?post=1263"},{"taxonomy":"license","embeddable":true,"href":"https:\/\/courses.lumenlearning.com\/wm-abnormalpsych\/wp-json\/wp\/v2\/license?post=1263"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}