In the DSM, abnormal behavior patterns are classified as “mental disorders.”Mental disorders involve either emotional distress (typically depression or anxiety)
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CHAPTER Classification and Assessment of Abnormal BehaviorCHAPTER OUTLINE HOW ARE ABNORMAL BEHAVIOR PATTERNS CLASSIFIED?70Ð77 The DSMand Models ofAbnormal Behavior STANDARDS OF ASSESSMENT77Ð80 Reliability Validity Cognitive Assessment Physiological Measurement SOCIOCULTURAL AND ETHNIC FACTORS IN ASSESSMENT99Ð100 SUMMING UP100Ð101 METHODS OF ASSESSMENT80Ð99 The Clinical Interview Computerized Interviews Psychological Tests Neuropsychological Assessment Behavioral Assessment 3NEVIDMC03_068-101HR.qxd 28-09-2007 14:34 Page 68

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69TFSome men in India have a psycho- logical disorder characterized by anxiety over losing semen. (p. 74) TFAlthough it is not an exact science, the measurement of the bumps on a personÕs head can be used to determine the personÕs personality traits. (p. 80) TFAn objective test of personality is one that does not require any subjective judgments on the part of the person taking the test. (p. 84) TFOne of the most widely used personality tests asks people to interpret what they see in a series of inkblots. (p. 88) TFPeople in weight-loss programs who carefully monitor what they eat tend to lose less weight than people who are less-reliable monitors. (p. 94) TFDespite advances in technology, physicians today must still perform surgery to study the workings of the brain. (p. 96) TFCocaine cravings in people addicted to cocaine have been linked to parts of the brain that are normally activated during pleasant emotions. (p. 99) FICTION TRUTH or“Jerry Has a Panic Attack on the Interstate” Interviewer:Can you tell me a bit about what it was that brought you to the clinic? Jerry:Well, . . .after the first of the year, I started getting these panic attacks. I didnÕt know what the panic attack was. Interviewer:Well, what was it that you experienced? Jerry:Uhm, the heart beating, racing . . . Interviewer:Your heart started to race on you. Jerry:And then uh, I couldnÕt be in one place, maybe a movie, or a church . . . things would be closing in on me and IÕd have to get up and leave. Interviewer:The first time that it happened to you, can you remember that? Jerry:Uhm, yeah I was . . . Interviewer:Take me through that, what you experienced. Jerry:I was driving on an interstate and, oh I mightÕve been on maybe 10 or 15 minutes. Interviewer:Uh huh. Jerry:All of a s udden I got this fear. I started to . . .uh race. Interviewer:So you noticed you were frightened? Jerry:Yes. Interviewer:Your heart was racing and you were perspiring. What else? Jerry:Perspiring and uh, I was afraid of driving anymore on that interstate for the fear that I would either pull into a car head on, so uhm, I just, I just couldnÕt function. I just couldnÕt drive. Interviewer:What did you do? Jerry:I pulled, uh well at the nearest exit. I just got off . . . uh stopped and, I had never experienced anything like that before. Interviewer:That was just a . . . Jerry:Out of the clear blue . . . Interviewer:Out of the clear blue? And whatÕd you think was going on? Jerry:I had no idea. Interviewer:You just knew you were . . . Jerry:I thought maybe I was having a heart attack. Interviewer:Okay. Source: Exerpted from ÒPanic Disorder: The Case of Jerry,Ó found on the Videos in AbnormalPsychologyCD-ROM that accompanies this textbook. JERRYBEGINSTOTELLHISSTORY ,GUIDEDBYTHEINTERVIEWER .PSYCHOLOGISTSANDOTHER mental health professionals use clinical interviews and a variety ofother means to assess abnormal behavior,including psychological testing,behavioral assessment,and physiological monitoring.The clinical interview is an important way ofassessing abnormal behavior and arriving at a diagnostic impressionÑin this case,panic disor- der.The clinician matches the presenting problems and associated features with a set ofdiagnostic criteria in forming a diagnostic impression. The diagnosis ofpsychological or mental disorders represents a way ofclassifying patterns ofabnormal behavior on the basis oftheir common features or symptoms. Abnormal behavior has been classified since ancient times.Hippocrates classified abnormal behaviors according to his theory of humors (vital bodily fluids).Although his theory proved to be flawed,HippocratesÕclassification ofsome types ofmental health problems generally correspond to diag nostic categories we use today.His descrip- tion ofmelancholia,for example,is similar to our current conception ofdepression. NEVIDMC03_068-101HR.qxd 28-09-2007 14:34 Page 69

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70Chapter 3During the Middle Ages some ÒauthoritiesÓclassified abnormal behaviors into two groups,those that resulted from demonic possession and those due to natural causes. The 19th-century German psychiatrist Emil Kraepelin was the first modern theorist to develop a comprehensive model ofc lassification based on the distinctive features,or symptoms,associated with abnormal behavior patterns (see Chapter 1).The most commonly used classification system today is largely an outgrowth and extension of KraepelinÕs work:the Diagnostic and Statistical Manual ofMental Disorders (DSM), published by the American Psychiatric Association. Why is it important to classify abnormal behavior? For one thing,classification is the core ofscience.Without labeling and organizing patterns ofabnormal behavior, researchers could not communicate their findings to one another,and progress toward understanding these disorders would come to a halt.Moreover,important decisions are made on the basis ofclassification.Certain psychological disorders respond better to one therapy than another or to one drug than another.Classification also helps clinicians pre- dict behavior:schizophrenia,for example,follows a more or less predictable course. Finally,classification helps researchers identify populations with similar patterns of abnormal behavior.By classifying groups ofpeople as depressed,for example,researchers might be able to identify common factors that help explain the origins ofdepression. This chapter reviews the classification and assessment ofabnormal behavior,begin- ning with the DSM.HOW ARE ABNORMAL BEHAVIOR PATTERNS CLASSIFIED? The DSMwas introduced in 1952.The latest version,published in 2000,is the DSM-IV-TR, the Text Revision (TR) ofthe Fourth Edition ( DSM-IV) (APA,2000).Another common system ofclassification,published by the World Health Organization,is used mainly for compiling statistics on the worldwide occurrence ofdisorders:the International Statistical Classification ofDiseases and Related Health Problems (ICD), which is now in its tenth revision (the ICD-10).The DSM-IVis compatible with the ICD,so that DSMdiagnoses could be coded in the ICDsystem as well.Thus the two systems can be used to share information about the prevalences and characteristics of particular disorders.The DSMhas been widely adopted by mental health professionals. However,many psychologists and other professionals criticize the DSMon several grounds,such as relying too strongly on the medical model.Our focus on the DSMreflects recognition ofits widespread use,not an endorsement. In the DSM,abnormal behavior patterns are classified as Òmental disorders.Ó Mental disorders involve either emotional distress (typically depression or anxiety),signifi- cantly impaired functioning (difficulty meeting responsibilities at work,in the family, or in society at large),or behavior that places people at risk for personal suffering,pain, disability,or death (e.g.,suicide attempts,repeated use ofharmful drugs). Let us also note that a behavior pattern that represents an expected or culturally appropriate response to a stressful event,such as signs ofbereavement or grieffollow- ing the death ofa loved one,is not considered disordered within the DSM,even if behavior is significantly impaired.Ifa personÕs behavior remains significantly impaired over an extended period oftime,however,a diagnosis ofa mental disorder might become appropriate. The DSMand Models of Abnormal BehaviorThe DSMsystem,like the medical model,treats abnormal behaviors as signs or symp- toms ofunderlying disorders or pathologies.However,the DSMdoes not assume thatabnormal behaviors necessarily reflect biological causes or defects.It recognizes that the causes ofmost mental disorders remain uncertain:Some disorders may have purely biological causes,whereas others may have psychological causes.Still others, probably most,are best explained within a multifactorial model that takes into account the interaction ofbiological,psychological,social (socioeconomic,sociocultural,and ethnic),and physical environmental factors. NEVIDMC03_068-101HR.qxd 28-09-2007 14:34 Page 70

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Classification and Assessment of Abnormal Behavior 71The authors ofthe DSMrecognize that their use ofthe term mental disorder is prob- lematic because it perpetuates a long-standing but dubious distinction between mental and physical disorders (American Psychiatric Association,1994,2000).They point out that there is much that is ÒphysicalÓin ÒmentalÓdisorders and much that is ÒmentalÓ in ÒphysicalÓdisorders.The diagnostic manual continues to use the term mental disorder because its developers have not been able to agree on an appropriate substitute.In this text we use the term psychological disorder in place of mental disorder because we feel it is more appropriate to place the study ofabnormal behavior more squarely within a psychological context.Moreover,the term psychological has the advantage ofencom- passing behavioral patterns as well as strictly ÒmentalÓexperiences,such as emotions, thoughts,beliefs,and attitudes. We should also recognize that the DSMis used to classify disorders,not people. Rather than classify someone as a schizophreni c or a depressive, we refer to an individ- ual with schizophrenia or a person with major depression .This difference in terminol- ogy is not simply a matter ofsemantics.To label someone a schizophrenic carries an unfortunate and stigmatizing implication that a personÕs identity is defined by the dis- order he or she has. Features of the DSMThe DSMis descriptive,not explanatory.It describes the diag- nostic featuresÑor,in medical terms,symptomsÑofabnormal behaviors;it does not attempt to explain their origins or adopt any particular theoretical framework,such as psychodynamic or learning theory.Using the DSMclassification system,the clinician arrives at a diagnosis by matching a clientÕs behaviors with the criteria that define par- ticular patterns ofabnormal behavior (Òmental disordersÓ).Table 3.1shows the diag- nostic criteria for generalized anxiety disorder. Abnormal behavior patterns are categorized according to the features they share. For example,abnormal behavior patterns chiefly characterized by anxiety,such as panic disorder or generalized anxiety disorder (see Table 3.1),are classified as anxiety disorders.Behaviors chiefly characterized by disruptions in mood are categorized as mood disorders.The DSMrecommends that clinicians assess an individualÕs mental state according to five factors,or axes.Together the five axes provide a broad range of information about the individualÕs functioning,not just a diagnosis (see Table 3.2). The system contains the following axes. 1.Axis I: Clinical Disorders and Other Conditions That May Be a Focus ofClinical Attention. This axis incorporates a wide range ofclinical syndromes,including anxiety disorders,mood disorders,schizophrenia and other psychotic disorders, TABLE 3.1 Sample Diagnostic Criteria for Generalized Anxiety Disorder 1.Occurrence of excessive anxiety and worry on most days during a period of 6 months or longer. 2.Anxiety and worry are not limited to one or a few concerns or events. 3.Difficulty controlling feelings of worry. 4.The presence of a number of features associated with anxiety and worry, such as the following: a.experiencing restlessness or feelings of edginess b.becoming easily fatigued c.having difficulty concentrating or finding oneÕs mind going blank d.feeling irritable e.having states of muscle tension f.having difficulty falling asleep or remaining asleep or having restless, unsatisfying sleep 5.Experiencing emotional distress or impairment in social, occupational, or other areas of functioning as the result of anxiety, worry, or related physical symptoms. 6.Worry or anxiety is not accounted for by the features of another disorder. 7.The disturbance does not result from the use of a drug of abuse or medication or a general medical condition and does not occur only in the context of another disorder. Source:Adapted from DSM-IV-TR(APA, 2000). NEVIDMC03_068-101HR.qxd 28-09-2007 14:34 Page 71

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72Chapter 3adjustment disorders,and disorders usually first diagnosed during infancy,child- hood,or adolescence (except for mental retardation,which is coded on Axis II). Axis I also includes relationship problems,academic or occupational problems, and bereavement,conditions that may be the focus ofdiagnosis and treatment but that do not in themselves constitute definable psychological disorders.Also coded on Axis I are psychological factors that affect medical conditions,such as anxiety that exacerbat es an asthmatic co ndition or depressive symptoms that delay recovery from surgery. 2.Axis II: Personality Disorders and Mental Retardation. Personality disorders are enduring and rigid patterns ofmaladaptive behavior that typically impair rela- tionships with others and social functioning.These include antisocial,paranoid, narcissistic,and borderline personality disorders (see Chapter 13).Mental retar- dation,which is also coded on Axis II,involves pervasive intellectual impairment (see Chapter 14). People may be given either Axis I or Axis II diagnoses or a combination ofthe two when both apply.For example,a person may receive a diagnosis ofan anxiety disorder (Axis I) anda second diagnosis ofa personality disorder (Axis II). 3.Axis III: General Medical Conditions. All medical conditions and diseases that may be important to the understanding or treatment ofan individualÕs mental disor- ders are coded on Axis III.For example,if hypothyroidism were a direct cause ofan individualÕs mood disorder (such as major depression),it would be coded under Axis III.Medical conditions that affect the understanding or treatment ofa mental disorder (but that are not direct causes ofthe disorder) are also listed on Axis III. For instance,the presence ofa heart condition may determine whether a particu- lar course ofdrug therapy should be used with a depressed person. 4.Axis IV: Psychosocial and Environmental Problems. The psychosocial and environ- mental problems that affect the diagnosis,treat ment,or outcome ofa mental disorder are placed on Axis IV.These include job loss,marital separation or divorce,home- lessness or inadequate housing,lack ofsocial support,the death or loss ofa friend,or TABLE 3.2 The Multiaxial Classification System of the DSM-IV-TR AxisType of Information Brief DescriptionAxis IClinical disordersThe patterns of abnormal behavior (Òmental disordersÓ) that impair functioning and are stressful to the indiv idual. Other conditions that may be a focus of clinical attention Other problems that may be the focus of diagnosis or treatment but do not constitute mental disorders, such as academic, vocational, or social problems, and psychological factors that affect medical conditions (such as delayed recovery from surgery due to depressive symptoms). Axis IIPersonality disordersPersonality disorders involve excessively rigid, enduring, and maladaptive ways of relating to others and adjusting to external demands. Mental retardationMental retardation involves a delay or impairment in the development of intellectual and adaptive abilities. Axis IIIGeneral medical conditionsChronic and acute illnesses and medical conditions that are important to the understanding or treatment of the psychological disorder or that play a direct role in causing the psychological disorder. Axis IVPsychosocial and environmental problems Problems in the social or physical environment that affect the diagnosis, treatment, and outcome of psychological disorders. Axis VGlobal assessment of functioningOverall judgment of current functioning with respect to psychological, social, and occupational functioning; the clinician may also rate the highest level of functioning occurring for at least a few mont hs during the past year. Source:Adapted from the DSM-IV-TR(APA, 2000). NEVIDMC03_068-101HR.qxd 28-09-2007 14:34 Page 72

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Classification and Assessment of Abnormal Behavior 73TABLE 3.3 Psychosocial and Environmental Problems Source:Adapted from the DSM-IV-TR(APA, 2000). Problem Categories Examples Problems with primary support groupDeath of family members; health problems of family members; marital disruption in the form of separation, divorce, or estrangement; sexual or physical abuse within the family; child neglect; birth of a sibling Problems related to the social environmentDeath or loss of a friend; social isolation or living alone; difficulties adjusting t o a new culture (acculturation); discrimination; adjustment to transitions occurring during the life cycle, such as retirement Educational problemsIlliteracy; academic difficulties; problems with teachers or classmates; inadequate or impoverished school environment Occupational problemsWork-related problems including stressful workloads and problems with bosses or coworkers; changes in employment; job dissatisfaction; threat of loss of job; unemployment Housing problemsInadequate housing or homelessness; living in an unsafe neighborhood; problems with neighbors or landlord Economic problemsFinancial har dships or extreme poverty; inadequate welfare support Problems with access to health care services Inadequate health care services or availability of health insurance; difficulties w ithtransportation to health care facilities Problems related to interaction with the legal system/crime Arrest or imprisonment; becoming involved in a lawsuit or trial; being a victim of crime Other psychosocial problemsNatural or human-made disasters; war or other hostilities; problems with caregivers outside the family, such as counselors, social workers, and physicians; lack of availability of social service agencies exposure to war or other disasters.Some positive life events,such as a job promotion, may also be listed on Axis IV,but only when they create problems for the individual, such as difficulties adapting to a new job.Table 3.3lists other examples from this axis. 5.Axis V: Global Assessment ofFunctioning. The clinician rates the clientÕs current level ofpsychological,social,and occupational functioning using a scale similar to that shown in Table 3.4.The clinician may also indicate the highest level offunctioning achieved for at least a few months during the preceding year.The level ofcurrent functioning indicates the current need for treatment or intensity ofcare.The level of highest functioning is suggestive ofthe level offunctioning that might be restored. Table 3.5shows an example ofa diagnosis in the DSMmultiaxial system for a hypothetical case.The person receives two diagnoses,an Axis I diagnosis ofgeneralized anxiety disorder (discussed in Chapter 6) and an Axis II diagnosis ofdependent per- sonality disorder (discussed in Chapter 13).The person also has a medical disorder (hypertension) and several psychosocial/environmental problems,as noted by the list- ing on Axis IV ofmarital separation and unemployment.The clinician also gives the person an overall rating of62 on the level offunctioning scale (GAF) on Axis V,which indicates that although the person is presenting with a mild level ofsymptoms or impaired functioning,he or she is functioning fairly well. Culture-Bound Syndromes Some patterns ofabnormal behavior,called culture- bound syndromes, occur in some cultures but are rare or unknown in others. Culture-bound syndromes may reflect exaggerated forms ofcommon folk supersti- tions and beliefpatterns within a particular culture.For example,the psychiatric disorder taijin-kyofu-sho (TKS) is common among young men in Japan but rare elsewhere.The disorder is characterized by excessive fear ofembarrassing or offending other people (Nakamura et al.,2002).People with TKS may dread blushing in front of culture-bound syndromes Patterns of abnormal behavior found within only one or a few cultures. NEVIDMC03_068-101HR.qxd 28-09-2007 14:34 Page 73

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Evaluating the DSMSystem To be useful,a diagnostic system such as the DSMmust demonstrate reliability and validity. The DSMmay be considered reliable,or consis- tent,ifdifferent evaluators using the system are likely to arrive at the same diagnoses when they evaluate the same cases.The system may be considered valid ifdiagnostic judgments correspond with observed behavior.For example,people diagnosed with social phobia should show abnormal levels ofanxiety in social situations.Another form ofvalidity is predictive validity, or ability to predict the course the disorder is like- ly to follow or its response to treatment.For example,people diagnosed with bipolar disorder typically respond to the drug lithium (see Chapter 8).Likewise,persons diag- nosed with specific phobias (such as fear ofheights) tend to be highly responsive to behavioral techniques for reducing fears (see Chapter 6). Overall,evidence supports the reliability and validity ofmany DSMcategories, including many anxiety and mood disorders,as well as alcohol and drug dependence disorders (Grant et al.,2006;Hasin et al.,2006).Yet questions about validity persist for some diagnostic classes,such as Axis II personality disorders,as well as Axis V, Global Assessment ofFunctioning (Moos,McCoy,& Moos,2000;Widiger & Simonsen,2005).Overall,it is fair to say that the validity ofthe DSMremains a sub- ject ofongoing debate and study (Hummelen et al.,2006;Kendell & Jablensky,2003; Watson & Clark,2006). Many observers have argued that the DSMshould become more sensitive to cul- tural and ethnic diversity.The behaviors included as diagnostic criteria in the DSMare determined by consensus ofmostly U.S.-trained psychiatrists,psychologists,and social workers.Had the American Psychiatric Association asked Asian-trained or Latin AmericanÐtrained professionals to develop their diagnostic manual,for exam- ple,there might have been some different diagnostic criteria or even different diag- nostic categories. In fairness to the DSM,however,the latest edition does place greater emphasis than did earlier editions on weighing cultural factors when assessing abnormal behavior.It recognizes that clinicians unfamiliar with an individualÕs cultural back- ground may incorrectly classify that individualÕs behavior as abnormal when it in fact falls within the normal spectrum in his or her culture.In Chapter 1we noted that the same behavior might be deemed normal in one culture but abnormal in another.The DSM-IV-TR specifies that in order to make a diagnosis ofa mental dis- order,the behavior in question must not merely represent a culturally expectable and sanctioned response to a particular event,even though it may seem odd in the light ofthe examinerÕs own cultural standards.The DSM-IV-TR alsorecognizes that abnormal behaviors may take different forms in differ- ent cultures and that some abnormal behavior patterns are culturally specific (see Table 3.6). All things considered,the current edition ofthe DSM,the DSM-IV- TR,is widely recognized as an improvement over previous editions, even though questions remain about the reliability and validity ofcer- tain diagnostic categories and about the specific criteria used to reach certain diagnoses (McGlinchey et al.,2006;Widiger & Clark,2000; Zimmerman et al.,2006). Advantages and Disadvantages of the DSMSystem The major advan- tage ofthe DSMmay be its designation ofspecific diagnostic criteria.The DSMpermits the clini cian to readil y match a clientÕs complaints and asso- ciated features with specific standar ds to see which diagnosis best fits the case.For example,auditory hallucinatio ns (Òhearing voicesÓ) and delu- sions (fixed,but false beliefs,such as thinking that other people are dev- ils) are characteristic symptoms ofschizophrenia. The multiaxial system paints a comprehensive picture ofclients by inte- grating information concerning abnormal behaviors,medical conditions that affect abnormal behaviors,psychosocial and environmental problems that may be stressful to the individual,and level offunctioning.The possibility ofmultiple diagnoses prompts clinicians to consider presenting Classification and Assessment of Abnormal Behavior 75reliability In psychological assessment, the consistency of a measure or diagnostic instrument or system. validity The degree to which a test or diagnostic system measures the traits or constructs it purports to measure. Assessment of level of functioning. The assessment of functioning takes into account the individualÕs ability to manage the respon- sibilities of daily living. Here we see a group home for people with mental retardation. The residents assume responsibility for household functions. Cultural underpinnings of abnormal behavior patterns. Culture-bound syndromes often represent exaggerated forms of cultural beliefs and values. TKS is characterized by excessive fear that one may embarr ass or offend other people. The syndrome primarily affects young Japanese men and appears to be con- nected with the emphasis in Japanese culture on politeness and avoiding embarrassing other people. NEVIDMC03_068-101HR.qxd 28-09-2007 14:34 Page 75

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76Chapter 3current problems (Axis I) along with the re latively long-standing personality problems (Axis II) that may contribute to them. Criticisms are also leveled against the DSMsystem.Critics challenge the utility of particular symptoms or features associated with particular syndromes or ofspecified diagnostic criteria,such as the requirement that major depression be present for 2 weeks before a diagnosis is reached (Faraone et al.,2006;Zimmerman et al.,2006).Others challenge the reliance on the medical model.In the DSMsystem,problem behaviors are viewed as symptoms ofunderlying mental disorders in much the same way that physical symptoms are signs ofunderlying physical disorders.The very use ofthe term diagnosis presumes the medical model is an appropriate basis for classifying abnormal behaviors.But some clinicians feel that behavior,abnormal or otherwise,is too TABLE 3.6 Examples of Culture-Bound Syndromes from Other Cultures Culture-Bound Syndrome DescriptionAmokA disorder principally occurring in men in Southeastern Asian an d Pacific Island cultures, as well as in traditional Puerto Rican and Navajo cultures in the West, it describes a type of dissociative episode (a s udden change in consciousness or self-identity) in which an otherwise normal person s uddenly goes berserk and strikes out at others, sometimes killing them. During these episodes, the person may have a sense of acting automatically or robotically. Violence may be directed at people or objects and is often accompanied by perceptions of persecution. A return to the personÕs usual state of functioning follows the episode. In the West, we use the expression Òrunning amuckÓ to refer to an episode of losing oneself and running around in a violent frenzy. The word amuckis derived from the Malaysian word amoq, meaning Òengaging furiously in battle.Ó The word passed into the English language during colonial times when British colonial rulers in Malaysia observed this behavior among the native people. Ataque de nervios (Òattack of nervesÓ) A way of describing states of emotional distress among Latin American and Latin Mediterranean groups, it most commonly involves features such as shouting uncontrollably, fits of crying, trembling, feelings of warmth or heat rising from the chest to the head, and aggressive verbal or physical behavior. These episodes are usually precipitated by a stressful event affecting the family (e.g., receiving news of the death of a family member) and are accompanied by feelings of being out of control. After the attack, the person returns quickly to his or her usual level of functioning, although there may be amnesia for events that occurred during the episode. Dhat syndrome A disorder (described further in Chapter 7) affecting m ales found principally in Indi a that involves intense fear or anxiety over the loss of semen through nocturnal emissions, ejaculations, or excretion with urine (despite the folk belief, semen doesnÕt actually mix with urine). In Indian culture, there is a popular belief that loss of semen depletes the man of his vital natural energy. Falling out or blacking out Occurring principally among southern U.S. and Caribbean groups, the disorder involves an episode of s udden collapsing or fainting. The attack may occur without warning or be preceded by dizziness or feelings of ÒswimmingÓ in the head. Although the eyes remain open, the indiv idual reports an inability to see. The person can hear what others are saying and understand what is occurring but feels powerless to move. Ghost sicknessA disorder occurring among American Indian groups, it involves a preoccupation with death and with the ÒspiritsÓ of the deceased. Symptoms associated with the condition include bad dreams, feelings of weakness, loss of appetite, fear, anxiety, and a sense of foreboding. Hallucinations, loss of consciousness, and states of confusion may also be present, among other symptoms. Koro Found primarily in China and some other South and East Asian countries, the syndrome (also discussed further in Chapter 7) refers to an episode of acute anxiety involving the fear that oneÕs genitals (the penis in men and the vulva and nipples in women) are shrinking and retracting into the body and that death may result. Zar A term used in a number of countries in North Africa and the Middle East to describe the experience of spirit possession. Possession by spirits is often used in these cultures to explain dissociative episodes (s udden changes in consciousness or identity) that may be characterized by periods of shouting, banging of the head against the wall, laughing, singing, or crying. Affected people may seem apathetic or withdrawn or refuse to eat or carry out their usual responsibilities. Source:Adapted from the DSM-IV-TR(APA, 2000); Osborne, 2001; and other sources. NEVIDMC03_068-101HR.qxd 28-09-2007 14:34 Page 76

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Classification and Assessment of Abnormal Behavior 77complex and meaningful to be treated as merely symptomatic.They assert that the medical model focuses too much on what may happen within the individual and not enough on external influences on behavior,such as social factors (socioeconomic,soci- ocultural,and ethnic) and physical environmental factors. Another concern is that the medical model focuses on categorizing psychological (or mental) disorders rather than describing peopleÕs behavioral strengths and weaknesses. Similarly,many investigators questio n whether the diagnostic model should retain its categorical structure (a disorder is either present or not).Perhaps,they argue,it should be replaced with a dimensional approach in which abnormal behavior patterns such as anxiety,depression,and personality disorders,re present extreme variations ofnormally occurring emotional states and psychological traits (e.g.,Akiskal & Benazzi,2005; Cuthbert,2005;First,2005,2006;Kupfer,2005;Prisciandaro & Roberts,2005). To behaviorally oriented psychologists,the understanding ofbehavior,abnormal or otherwise,is best approached by examining the interaction between the person and the environment.The DSMaims to determine what ÒdisordersÓpeople ÒhaveÓÑnot how well they can function in particular situatio ns.The behavioral model,alternatively, focuses more on behaviors than on underlying processesÑmore on what people ÒdoÓ than on what they ÒareÓor Òhave.ÓBehaviorists and behavior therapists also use the DSM,ofcourse,in part because mental health centers and health insurance carriers require the use ofa diagnostic code and in part because they want to communicate in a common language with other practitioners.Many behavior therapists view the DSMdiagnostic code as a convenient means oflabeling patterns ofabnormal behavior,a shorthand for a more extensive behavioral analysis ofthe problem. Critics also complain that the DSMsystem might stigmatize people by labeling them with psychiatric diagnoses.Our society is strong ly biased against people who are labeled as mentally ill.They are often shunned by others,including even family members,and subjected to discriminationÑor sanism(Perlin,1994),the counterpart to other forms ofprejudice,such as racism,sexism,and ageismÑin housing and employment. The DSMsystem,despite its critics,has become part and parcel ofthe everyday practice ofmost U.S.mental health professionals.It may be the one reference manual found on the bookshelves ofnearly all professionals and dog-eared from repeated use. Perhaps the DSMis best considered a work in progress,not a final product.Work on the fifth edition ofthe DSMÑtheDSM-V Ñwas well underway at the time ofthis writ- ing (Krueger & Markon,2006;McGorry,2007).In the nearby Controversies in Abnormal Psychology feature,a prominent investigator in the field,Thomas Widiger, shares his views on the DSM,or what he refers to as the ÒB ible ofPsychiat ry.ÓDr.Widiger also discusses the dimensional approach to assessing personality disorders such as antisocial personality disorder.(See Chapter 13for a description ofthe features of antisocial personality disorder and other personality disorders). Now let us consider various ways ofassessing abnormal behavior.We begin by considering the basic requirements for methods ofassessmentÑthat they be reliable and valid.STANDARDS OF ASSESSMENT Important decisions are made on the basis ofclassification and assessment.For exam- ple,recommendations for specific treatment techniques vary according to our assessment ofthe problems clients exhibit.Therefore,methods ofassessment,like diagnostic categories,must be reliable and valid.Reliability The reliability ofa method ofassessment,like that ofa diagnostic system,refers to its con- sistency.A gauge ofheight would be unreliable ifpeople looked taller or shorter at every measurement.A reliable measure ofabnormal behavior must also yield the same results on different occasions.Also,different peo ple should be able to check the yardstick and sanismThe negative stereotyping of people who are identified as mentally ill. NEVIDMC03_068-101HR.qxd 28-09-2007 14:34 Page 77

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