The Diagnostic Manual for Mental Disorders - Coursework Example

The Diagnostic Manual for Mental Disorders Introduction Personality is the pattern of thoughts, behavior and feelings that make up an individual (Compass, 2009). People’s personalities change and develop as their circumstances changes thus making them behave in ways that are either predictable or unpredictable. People also tend to be flexible once they learn from their past experiences and they also change their behavior in order to cope with the circumstances effectively. However, somebody with a personality disorder is highly likely to be very inflexible. Their attitudes and behavior is quite limited and may seem to be different form people’s expectations, culture and background. Their behavior and attitude often disturbs them and the people around them (APA, 1987). Personality disorders are usually noticed in early adulthood or in adolescence but it may sometimes begin in childhood since this is the stage where the personality is shaped and developed. The affected individuals experience difficulty in developing friendships, maintaining stable relationships, work in cooperation with others, since their coping strategies and responses are limited. It is common that such individuals show some tendencies of being suicidal as compared to the average individual and they sometimes feel alone and alienated. The lives of the people suffering from personality disorders and the people that live with them are made to feel disrupted to different degrees (Bateman & Fonagy, 1999). In addition to that, stressful events may trigger the disorders making the individual have an unpredictable behavior. The Diagnostic Statistical Manual of Mental Disorders (DSM) is work that is normally consulted by physicians, psychologists and psychiatrists, social workers, medical students, professionals in social service and health care fields (APA, 1994). The three purposes of DSM is to make a provision for a guide that is helpful to clinical practice, to promote the efficiency in communication and research among researchers and clinicians and to play the role of an educational tool (Collins, 2001). The manual has come under criticism in the way in which personality disorders are described. In the same light, this essay will critique the way in which personality disorders are described in the current version of the DSM (IV-TR). It will also select an alternative approach that illustrates a better way to describe personality disorders in the light of current scientific knowledge. Overview of DSM (IV- TR) The abbreviation DSM-IV-TR stands for fourth edition, text revision of the manual which was published in the year 2000 (APA, 2000). This version of the manual classifies mental disorders, guides professionals in determining diagnosis, and attaches numerical codes to every disorder in order to facilitate record keeping. In its introduction, the manual states that it intends to be applicable in a variety of fields and to be a usable tool by researchers and clinicians in different orientations such as biological fields, psychodynamic, behavioral, cognitive, inter-personal and family fields. The most important element of the DSM-IV-TR is that it has a descriptive text accompanying the criteria for every personality disorder (APA, 2010). The DSM-III that was introduced in 1980 came up with a five axes system for assessing the mental disorder of a patient and his or her emotional health (Coid, 2006). The system is structured in such a way that concurrent or complex mental disorders appear comprehensive. In that regard, the DSM-IV-TR intends to use the system in the application of the biopsychosocial model in research, educational and clinical settings (Diamond, 2001) Since the DSM-IV-TR uses the biopsychosocial model, it means that it does not use any kind of theory within psychiatry that is concerned with the origin or cause of mental disorders. In other words, it does not use theories in diagnosing and classification; that is the categories and axes lack representation of overarching theories concerning the nature of the mental disorders (Fisher, 2001) The five axes presented in the DSM-IV-TR manual are specific to the type of disorders they address. For instance the first Axis addresses clinical disorders which are mood disorders, anxiety disorders, schizophrenia and many more psychotic disorders. The second axis deals with mental retardation and personality disorders. Here, the clinician or psychiatrist uses criteria for guidance in order to determine whether a patient is suffering from a personality disorder. The third axis addresses general medical conditions which include disorders related physiologically to a mental disorder; diseases that dictate the choice of drugs used for treatment, or diseases that are severe enough to affect the functioning or mood of the patient. The fourth axis dwells on environmental and psychological problems. These are situations or conditions that affect the treatment or diagnosis of the mental disorder of the patient. In addition to that, DSM-IV-TR categorizes the following problems: family problems, educational problems, social problems, housing problems, legal system problems, economic problems and limited health care problems (Hill, 2003). Finally, the fifth axis performs a general functioning assessment (Jaspers, 1963). By rating the general functioning level of the patient, the doctor is in a position to come up with a treatment plan that will aid in evaluation of treatment progress. In its assessment, the measurement of interpersonal relationships can be determined, for instance stability and maturity can be determined. Critique of DSM-IV-TR Many criticisms about DSM-IV-TR have arisen following the publication of the manual. Many of these criticisms come from researchers, psychiatrists and clinical psychologists who use the manual as a reference in determining whether patients are suffering from personality disorders. For instance, a person suffering from Schizophrenia may visit a psychiatrist and be diagnosed with the same disease but if the same patient visits a new psychiatrist, he may be diagnosed with schizoaffective disorder. It goes without saying that the patient may suspect malpractice. However, it may be entirely true that the patient actually met the criteria for schizophrenia and may have changed with time and thus meet the criteria for schizoaffective disorder or a related symptom. Therefore, the problem does not lie with the psychiatrists but with the manual that has its own limitations that have been poorly understood. Furthermore, the fact that the manual clearly appreciates that it is possible for a patient to satisfy the criteria for two different personality disorders, it fails to give a treatment to this reason. The judgment and decisions made on how to determine whether an individual has a personality disorder or not, as stated in the DSM-IV-TR, are determined by psychiatric and medical professionals. However, they are measuring people according to normal standardized behavior that has been identified despite their cultural backgrounds. DSM-IV-TR has three clusters containing personality disorders which are odd or eccentric for cluster A, dramatic or emotional for cluster B and anxious or fearful for cluster C. The categorical system offers many advantages such as the decision of providing treatment or not, it is easy to use since it can easily be communicated and conceptualized to the doctor. However, this categorical system has been open to various criticisms. The categorical approach of the manual is highly doubtful especially when it states that personality disorders are clinical syndromes that are qualitatively distinct (Widiger, 2000). The thresholds for diagnosis between abnormal and normal are absent and some are weakly supported. Categories for personality disorders vary regarding traits and symptoms in the manual uses 256 combination of symptoms that guide doctors in diagnosing personality disorders (Widiger et al, 2001). The manual seems to forget to consider the idea that diagnoses seem not to be stable in a given span of time. In addition to that, few psychologists have been given the chance to give their clinical judgment concerning the diagnoses in the manual. The Factitious Disorder (FD) category in DSM-IV-TR is guided by criteria that can lead a psychiatrist to diagnose an individual suffering from the personality disorder. The main problem with the first criteria which specifies intentional feigning or display of signs of illness, fails to address the real nature of FD’s pathology; that is, the representations of illness by the patient are lies (Paul, 1999). The focus on the symptoms of the disorder has led to neglecting of other types of chronic lying and pretences that are not present in the DSM-IV-TR like false confessions, imposture and pseudologia fantastica. Furthermore, since the manual has failed to dwell on the role that imposture and falsification plays the criteria fails to distinguish intentional self harm by patients suffering from FD from the intentional self-harm initiated by patients who engage in harmful acts like cutting themselves and head banging. In addition to that, the DSM-IV-TR the second and third criteria have distinguished between Factitious Disorder and disorders that involve non-deceptive self-harm. The two criteria state that the motivation for self- harmful behavior especially in FD is due to an internal reward that is associated with taking the role of a sick person. However, general knowledge states that patients who are involved in self-harmful behavior such as cutting oneself also have the desire to satisfy an inner feeling; that is, the cutting of their bodies gives them internal joy. This is no different from what the manual says about Factitious Disorder. Therefore, this approach is logically flawed and very unhelpful to psychiatrists in distinguishing the different types of self-harm. People suffering from Borderline Personality Disorder have unstable relationships which are intense, impulsive behavior, major changes in moods, inappropriate anger, have a weak sense of identification, engage in self-harm, and have feelings of emptiness, experience long-term boredom and fear being abandoned. Such people cling to relationships that are very damaging since they lack the sense of self-identity and have a deep fear of being alone. The DSM-IV-TR has overstretched and simplified the Borderline Personality Disorder (BPD). The manual permits remission in a year’s time which is different from a personality construct thus raising serious flaws associated with the manual. In addition to that, the DSM-IV-TR fails to distinguish a clear relationship between Axis I and Axis II disorders and how developmental and childhood problems affect personality disorders. In other words, this section of the manual has not clarified the effect of childhood experiences on the development of an individual’s personality. The diagnoses that are differential seem to be unclear and personality disorders have not been demarcated sufficiently. Thus this has led to excessive co-morbidity, meaning, there are multiple diagnoses for Axis II due to the lack of clarity in criteria for diagnosing. It thus explains why a psychiatrist may have a different diagnosis for a patient while another may have a different opinion due to the multiple diagnoses presented in the Axis. It also explains why psychopaths can be diagnosed as narcissists or borderlines. In addition to that, the DSM-IV-TR lacks discussion of how to distinguish normal character which forms an individual’s personality, personality style and personality traits from personality disorders yet such a distinction is important when carrying out diagnosis. There is also a perceived cultural bias especially when addressing schizophrenic and antisocial personality disorders. Although the manual has a list of syndromes for use on racially and culturally diverse clients, it is not an exhaustive list and it shows some limitations when used in assessing and diagnosing people of color (Nooney, 2006). In addition, the DSM-IV-TR manual should not be manipulated by practitioners so that they may address the personality disorders of patients without finding out the unique experiences of the patient. This is because there are a whole lot of differences that exist between individuals and culture and the manual have failed to capture this concept. The categorical model that is used in the determination of personality disorders make human beings to be reduced to one-dimensional data sources (McHugh, 1992). This means that practitioners are prevented from reaching out into the whole person and treating them. In addition to that, the criteria in DSM-IV-TR are based on symptoms that have led to the multiplication of personality disorders and mental conditions. The categorical approach has made the manual to be open to politically related definitions of new disorders and dropping older ones. Moreover, some diagnostic categories of DSM-IV-TR almost define some of the personality differences and temperaments as mental disorders. This means that even the common occurrence of some traits in people who are considered to be normal are said to have a mental disorder. This makes that manual have serious flaws. In addition, DSM-IV-TR has put a lot of emphasis on biological psychiatry making people believe that the problems that they face in life can be done away with by taking pills. This means that people would no longer believe in talking about their problems to counselors but would prefer a quick fix for their issues by swallowing pills. In the long run, this may result in the psychological dependence on drugs and it will, in no way, solve the issues of personality disorders but rather escalate them. The DSM-IV-TR criteria fail to make an adequate difference between poor adaptation to problems that may be ordinary from true psychopathology (Terry & Bateman, 2004). In addition, the classification in the manual fails to acknowledge disorders that relate to uncontrolled anger, aggression and hostility. The manual has only used the intermittent explosive disorder to cater for these expressions associated with social problems (Ozarin, 1998). It has only used a class of disorders that deals with anxiety and depression. By using the categorization of personalities, the DSM-IV-TR fails to capture other types of personality disorders that are numerous. In addition to that, the manual displays the scarcity of clinical experiences that has been documented regarding the personality disorders and the utility of different modes of treatment. Moreover, the DSM-IV-TR uses diagnostic criteria that satisfy only a limited part of the criteria that is used by psychiatrists to diagnose a personality disorder. Hence, people who are diagnosed with similar personality disorders may share a single criterion or none at all. This variety of diagnosis is non-scientific and unacceptable. Dimensional Model The dimensional model can be used as an alternative approach to describe personality disorders in the DSM V since the categorical approach used in the DSM-IV-TR comes with many challenges in diagnosing personality disorders. The model attempts to split personality into small components and provides personality profiles based on scores. The categorical approach has also been seen to have serious flaws. A dimensional model also relates disorders to points on a continuum (APA, 2010). For instance, researchers in the field of psychology propose that there may be an underlying factor that connects all internalizing disorders. Such internalizing disorders may be anxiety, depression among others while externalizing disorders may be disorders related to substance use or antisocial personality disorder. This model also makes a provision for scores that are reliable and unlike the other DSM-IV-TR, they aid in the explanation of symptom heterogeneity through understanding of personality traits and its dimensions, explains the lack of distinction in categorical diagnoses, allow the integration of scientific findings that explain various personality traits and retains information concerning sub threshold symptoms that are of clinical interest. The word dimensional is used to bring out the variety of approaches used in quantifying personality and the pathology of personality (Karasic & Drescher, 2004). The model quantifies each disorder by indicating the extent of the symptoms in each personality disorder described in the DSM manual. It uses scores to represent the criteria number in each disorder or rating to indicate the extent of the criteria representing the personality disorder. This approach is better than the categorical approach since the symptoms of the personality are brought out clearly by the scores and they relate well to the scores of functional impairment (Kutchins & Kirk, 2000). In the same light, providing quantitative ratings for personality variations helps to address the problems that were cited in the categorical model by practitioners. Another way of describing personality would be to determine the degree of the presentation of an individual to a prototype in the DSM-IV-TR personality disorder. In other words, individuals that have met the diagnostic criteria regarding a personality trait may be considered as prototypic, or as moderately present if some of the criteria that is beyond the categorical diagnosis’ threshold is present. On the other hand, the patients may be regarded as threshold if they qualify for diagnostic threshold or they may also be referred to as sub threshold if the symptoms of the personality disorder are present but are below diagnostic threshold. In addition to that, individuals may also be termed as traits if no more than three symptoms of the personality disorder are present and absent if none of the diagnostic criteria are present. Conclusion Personality traits develop from early childhood and they are shaped depending on the environment and people that surround an individual when growing up. Personality disorders therefore result when individuals are not in a position to adjust to their environment and they prove to be difficult to live with and at the same time they find it difficult to understand way they behave the way they do. The DSM-IV-TR manual addresses the mental disorders than human beings suffer from and it lays down criteria that practitioners use in order to diagnose personality disorders. The manual uses the categorical model where it divides personality disorders into three clusters. Each cluster is then defined by specific criteria that will be used to determine whether an individual suffers from a personality disorder. This categorical model has been open to criticisms since it has its own limitations that have been poorly understood leading to diagnosis of more than one personality disorder to a single patient. The model has also failed in addressing the various types of personality disorders that may be present in the human population. Therefore, an alternative way of describing personalities in a clear and concise manner would be the Dimensional approach; which has been proposed to be included in the DSM V. This approach recognizes the weaknesses of the categorical model and uses a more precise and definitive way of diagnosing personality disorders. References Bateman, A. and Fonagy, P. (1999) .The Effectiveness of Partial Hospitalisation In The Treatment Of Borderline Personality Disorder – A Randomised Controlled Trial.  American Journal of Psychiatry, 156, pp. 1563-1569. Coid, J. (2006). Prevalence and Correlates of Personality Disorder in Great Britain. British Journal of Psychiatry, 188, pp. 423-431. Collins, G. (2001). Radical Makeover Proposed for DSM. Clinical Psychiatry News, 29(1) Diagnostic and Statistical Manual of Mental Disorders (1987). Washington, DC: American Psychiatric Association Diagnostic and Statistical Manual of Mental Disorders, 4th ed (1994). Washington, DC: American Psychiatric Association. Diagnostic and Statistical Manual: DSM-IV-TR., (2000). Washington: American Psychiatric Association. Diamond, A., (2001, November 18). A Conceptual Structure for Diagnoses. Psychiatric Times, pp. 4-5 Fisher, B., (2001). Recovering from Schizophrenia. Clinical Psychiatry News, 29, pp.30 Hill, J. (2003). Early Identification of Individuals at Risk for Antisocial Personality Disorder. British Journal of Psychiatry, 182, pp. 11-14. Jaspers, K. (1963) General Psychopathology. Chicago: University of Chicago Press  Karasic, D. and Drescher, J., (2004). Sexual and gender diagnoses of the Diagnostic and Statistical Manual (DSM-IV-TR). Haworth press. Retrieved April 23, 2010, from http://www.books.google.com/books Kutchins, H., and Kirk, S. (2000). The Conflict Over New Psychiatric Diagnoses. Health and Social Work 14, pp. 91-101. McHugh, R (1992). A Structure for Psychiatry at the Century's Turn: The View from Johns Hopkins. Journal of the Royal Society of Medicine, 85, pp. 483-487. Nooney, G. (2006). What is the DSM 4 - TR? Retrieved April 22, 2010 from http://dsm4tr.com/whatis.html Ozarin, D. (1998, April 3). DSM: A Brief Historical Note. Psychatric News. Paul R, (December 1999). How Psychiatry Lost Its Way. Commentary 108, pp. 67-72. Personality and Personality Disorders: DSM-5 Development (2010). Washington: American Psychiatric Association Development. Retrieved April 22, 2010 from http://www.dsm5.org/ProposedRevisions/Pages/PersonalityandPersonalityDisorders.aspx Terry, P. and Bateman, A. (2004). Drug treatment for personality disorders. Advances in Psychiatric Treatment, 10 (5), pp. 389-398. Widiger, T., Simonsen, E., and Regier, D. (2001). Dimensional Models of Personality Widiger, T. (2000). Adult Psychopathology: Issues and Controversies. Annual Review of Psychology, 23(5). Read More

It will also select an alternative approach that illustrates a better way to describe personality disorders in the light of current scientific knowledge. Overview of DSM (IV- TR) The abbreviation DSM-IV-TR stands for fourth edition, text revision of the manual which was published in the year 2000 (APA, 2000). This version of the manual classifies mental disorders, guides professionals in determining diagnosis, and attaches numerical codes to every disorder in order to facilitate record keeping.

In its introduction, the manual states that it intends to be applicable in a variety of fields and to be a usable tool by researchers and clinicians in different orientations such as biological fields, psychodynamic, behavioral, cognitive, inter-personal and family fields. The most important element of the DSM-IV-TR is that it has a descriptive text accompanying the criteria for every personality disorder (APA, 2010). The DSM-III that was introduced in 1980 came up with a five axes system for assessing the mental disorder of a patient and his or her emotional health (Coid, 2006).

The system is structured in such a way that concurrent or complex mental disorders appear comprehensive. In that regard, the DSM-IV-TR intends to use the system in the application of the biopsychosocial model in research, educational and clinical settings (Diamond, 2001) Since the DSM-IV-TR uses the biopsychosocial model, it means that it does not use any kind of theory within psychiatry that is concerned with the origin or cause of mental disorders. In other words, it does not use theories in diagnosing and classification; that is the categories and axes lack representation of overarching theories concerning the nature of the mental disorders (Fisher, 2001) The five axes presented in the DSM-IV-TR manual are specific to the type of disorders they address.

For instance the first Axis addresses clinical disorders which are mood disorders, anxiety disorders, schizophrenia and many more psychotic disorders. The second axis deals with mental retardation and personality disorders. Here, the clinician or psychiatrist uses criteria for guidance in order to determine whether a patient is suffering from a personality disorder. The third axis addresses general medical conditions which include disorders related physiologically to a mental disorder; diseases that dictate the choice of drugs used for treatment, or diseases that are severe enough to affect the functioning or mood of the patient.

The fourth axis dwells on environmental and psychological problems. These are situations or conditions that affect the treatment or diagnosis of the mental disorder of the patient. In addition to that, DSM-IV-TR categorizes the following problems: family problems, educational problems, social problems, housing problems, legal system problems, economic problems and limited health care problems (Hill, 2003). Finally, the fifth axis performs a general functioning assessment (Jaspers, 1963). By rating the general functioning level of the patient, the doctor is in a position to come up with a treatment plan that will aid in evaluation of treatment progress.

In its assessment, the measurement of interpersonal relationships can be determined, for instance stability and maturity can be determined. Critique of DSM-IV-TR Many criticisms about DSM-IV-TR have arisen following the publication of the manual. Many of these criticisms come from researchers, psychiatrists and clinical psychologists who use the manual as a reference in determining whether patients are suffering from personality disorders. For instance, a person suffering from Schizophrenia may visit a psychiatrist and be diagnosed with the same disease but if the same patient visits a new psychiatrist, he may be diagnosed with schizoaffective disorder.

It goes without saying that the patient may suspect malpractice. However, it may be entirely true that the patient actually met the criteria for schizophrenia and may have changed with time and thus meet the criteria for schizoaffective disorder or a related symptom.

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