DSM Research Paper

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As human beings, we are inherently social animals. We pay a great deal of attention to the behaviors, thoughts, and emotions of the people around us. Our interpersonal interactions occupy our minds for most of our daily existence. As members of a culture, we have various expectations about how others will behave and, in particular, how they will behave with us when we interact with them. However, there are some people who do not seem to follow the rules. Their behavior seems unusual, abnormal, and even unexplainable to us. Trying to explain the unexplainable in others is a fascinating topic. Most of us, at one time or another, have tried to develop some way of understanding abnormal behavior in others.

The act of classifying objects allows humans to comprehend the world. Classification is a fundamental process that all people have experience with, whether or not they are aware of it. From simple tasks like finding cereal in the grocery store to the complexity of creating a naming system for all living organisms, classification helps us organize our world.

Classification also serves as the foundation and starting point for all sciences. When a zoologist is presented with an organism that dwells mainly at the bottom of the ocean with a fivefold symmetry and fluid-filled tube feet, a classification system allows the zoologist to recognize this organism as part of the phylum Echinodermata, with the common name of starfish. A chemist is given a metal to experiment with and is told it is barium. Because of the classification system of the periodic table, the chemist immediately knows it is an alkaline earth metal with the properties of being soft and reacting with water and alcohol. Scientists rely on the structure and properties of their respective classification system to manage better the wealth of information contained within their fields.

Classification is the cornerstone of science for mental health professionals as well. Instead of being presented with marine-dwelling organisms or alkaline earth metals, psychologists and psychiatrists are faced with more abstract and ambiguous “objects” to classify in the form of mental disorders. For example, a mental health professional may be presented with the following case:

Marianne is a single, obese, 38-year-old woman who works at a mortuary. She has been employed at the mortuary since the death of her mother. Marianne’s lifestyle is very uneventful and bland. She lives as though others around her do not exist. To the outside observer, she seems sad and shows no emotional responses to the world around her. Her daily routine consists of riding the subway back and forth to work and falling asleep each night after her dinner in front of the TV. However, on one occasion, while riding on the subway, Marianne becomes fascinated with the voice of one subway driver and is determined to learn about this man. Marianne becomes obsessed with trying to find him and begins to miss work. She buys a subway schedule and sets her watch to match the subway clocks. She even follows him home one day and lingers outside his apartment door, where she discovers that he is married. Distraught and broken that her relationship with the subway driver will not happen, Marianne buys a fancy dress, makes up her face, and goes to the subway station the following day. She buys a candy bar, stands near the subway track, and dangerously leans over the track holding out the candy bar, waiting for her subway driver to arrive.

A clinician’s job would be to take this clinical information and attempt to understand what psychological problems are present and what course of action needs to be taken toward treating those problems. Such questions are guided by the classification system mental health professionals use to organize mental disorders, just as zoologists or chemists use their classification system to understand the phenomenon being studied.

There are several general purposes that a classification system should accomplish. The first is to provide a nomenclature, or a system of names that are assigned to objects or concepts that are grouped together in a classification. In terms of psychology and psychiatry, the standard assignment of names for disorders allows clinicians to convey clinical information in a short and efficient manner. For example, a name that might be applied to Marianne is the diagnosis of dependent personality disorder. What this name conveys is that Marianne has a personality style that is impeding functional interpersonal relationships. If professionals were not using a standard terminology, then communication about clinical symptoms and treatment could not exist.

The second function of classification is to provide a structure so that information can be retrieved easily (information retrieval). When a clinician is presented with a name of a mental disorder, a classification system aids in retrieving information about that disorder, such as its symptoms, etiology, course, and interventions used to treat it. Therefore, a classification system is not only an organization of names but also an organization-and-retrieval system of information associated with those names. For instance, now that Marianne has been given a diagnosis, the reader could open an abnormal psychology textbook to learn about this diagnosis and what treatments for this condition might be used.

The third purpose of classification provides a description of groups of symptoms that commonly occur together. In other words, if two individuals are diagnosed with the same mental disorder, then a classification system should indicate that these two individuals share the same symptoms. These two individuals should be differentiated from another individual who is diagnosed with a completely different disorder. This function allows clinicians to establish boundaries between different symptom patterns and to group together symptom patterns that have similar characteristics. The diagnosis of dependent personality disorder, to the extent that it is accurate, provides a shorthand description of her symptoms—for example, the intensity of the bond with her mother was such that she sought employment at the mortuary that buried her.

Prediction is the fourth goal of classification. Once a diagnosis of a patient is determined, it is useful to know the development and course of the symptoms associated with the disorder. Prediction is a valued goal of a classification system, as it provides the clinician with crucial information to establish effective treatment plans. Suppose that Marianne actually starts a relationship with the married subway driver. The diagnosis of dependent personality disorder might help her therapist predict what might occur if this man decided to reject Marianne and return to his wife.

The fifth function of classification is to allow a foundation for theories to emerge. A solid classification system stimulates ideas and questions that help professionals to understand and test the system’s own theoretical underpinnings, and also generates theories about the phenomena being classified. For example, the psychiatric classification has generated theoretical debates about the causes of mental disorders and how these causes can influence treatment. The diagnosis of dependent personality disorder, for example, is historically derived from Freud’s stage theory of development. According to Freudian theory, individuals with this type of personality are embedded in an “oral stage” of development that is similar to an infant who is breast-feeding. Like an infant, these individuals see the world through the eyes of a loved person (mother, lover, etc.). Strangers who intrude into this interpersonal world are met with crying and fearfulness.

The final purpose of classification is the social, political, and economic functions it serves (socio-politico-economic functions). The psychiatric classification system influences research agendas at governmental and private institutions, mental health funding, social and health policies, and management of psychopathology, in terms of what care is available to individuals with mental disorders. Political battles have erupted over what symptom presentations should be considered representative of mental disorders. Insurance companies use psychiatric classification to determine what disorders warrant reimbursement. In the feminist literature, for example, dependent personality disorder has been criticized as a diagnosis primarily aimed at women who are forced into subservient roles by a dominant male culture. Being dependent may be the most adaptive choice that many women have in social and occupational situations. Thus, some feminist critics would argue that this diagnosis needlessly stigmatizes women whose adaptations to their social context are perfectly reasonable.

This research-paper will address several aspects of the classification of mental disorders. The first section will outline the history of the official system of the classification of mental disorders and attempt to describe its current structure. The next section will raise several central issues regarding classification and how the current system addresses or fails to address each. Afterward, the chapter turns to discuss an alternative classification system that is gaining some popular support in the field. The chapter will close with a discussion of where future classification systems might go, and what issues the science of psychopathology needs to face.

History And Structure Of The DSM

In the United States, there is an official classification system for all mental disorders. This system is known as the Diagnostic and Statistical Manual of Mental Disorders. However, because this name is cumbersome and because psychologists love abbreviations, the usual name for this classification is the DSM.

Prior to the publication of the first DSM in 1952, there were at least three main classification systems for mental disorders in use in the United States, and many states and even individual hospitals had their own idiosyncratic classification systems. The use of multiple classification systems created great confusion among clinicians because there was no standard language for communicating information about patients with mental disorders. Hospitals were required to submit statistics on the number and type of patients admitted, but this was an impossible task because no one agreed on the “types.”

The American Psychiatric Association (APA), the main organization to which psychiatrists belong, recognized that something had to be done to unify the diagnostic process in the United States, so they created the first DSM. The APA had a long-standing Committee on Nomenclature and Statistics that had the task of defining and delimiting the types of psychopathology. It fell to this committee, led by George N. Raines, to create the first DSM. The resulting classification included 108 disorders, roughly divided into two halves: organic disorders and functional disorders. Organic disorders were considered to be physical malfunctions in the brain, whereas functional disorders were psychological in origin without a known physical correlate. The functional disorders were all termed “reactions” as a result of the influence of Adolf Meyer’s psychobiological theory. The term “reaction” implies that the symptoms are a result of some internal mechanism in the person interacting with an event in the outside environment, in direct contrast with the terms “disorder” or “disease,” which imply nothing about the role of the environment.

Each category in the first DSM was defined in a prose paragraph that included both behavioral and trait-like criteria. These descriptions were very short, rarely over 200 words, and added little to what meaning can be derived from the name of the disorder itself. For example, the description of passive-dependent personality follows: “This reaction is characterized by helplessness, indecisive-ness, and a tendency to cling to others as a dependent child to a supporting parent” (APA, 1952, p. 38). In many ways, this description is simply a definition of what the authors mean by the word “dependent.” However, the terms included are often relative, like “indecisiveness,” and thus are left to the discretion of the diagnosing psychiatrist to interpret. Who, at one time or another, has not been indecisive? To what degree must a person be indecisive before it is considered a problem? Individual psychiatrists were left to create their own answers to these questions. It was not clear how many of the symptoms listed in the description were necessary for a diagnosis, as rarely did a patient ever present with all the symptoms. As a result, two psychiatrists could diagnose the same patient with entirely different disorders, which is known as the problem of diagnostic reliability.

The DSM-II (1968) was largely the same in structure as the DSM-I, adding only a few more categories. The greatest difference was the dropping of the term “reaction” from the names of the disorders, which psychiatrists considered to imply too much about the nature and cause of the disorder. Often, the cause of the disorder was completely unknown, and the authors of the DSM-II did not want to be misleading.

Following the publication of the DSM-II, psychiatry began to receive considerable criticism regarding the subjective and unstable nature of diagnosis (Kendell, Cooper, & Gourley, 1971; Rosenhan, 1973; Szasz, 1961). The reliability of diagnosis between any two psychiatrists was very low, which limited the usefulness of the classification system. Philip Ash, a resourceful psychology student at the time, published a well-known study in which three psychiatrists independently interviewed 52 individuals (Ash, 1949). These three psychiatrists agreed on the diagnosis of only 20 percent of the individuals whom they saw. Because clinicians were so variable in their use of diagnoses, researchers who studied patients could not be certain that they were investigating the same disorder. Thus, generalizing research findings was quite difficult. Insurance companies were reluctant to reimburse patients for psychiatric services because it could not be known if they were receiving the appropriate treatment.

Therefore, the creators of the DSM-III (1980) set out to revise the manual in such a way as to increase diagnostic reliability. They did so through abandoning the prose descriptions used in DSM-I and DSM-II in favor of “diagnostic criteria.” They defined disorders by a list of symptoms. The presence or absence of these symptoms formed a “rule” by which a clinician would decide if a patient merited a particular diagnosis. Marianne would qualify for a diagnosis of dependent personality disorder only if she met the following criteria:

(a) Passively allows others to assume responsibility for major areas of life because of inability to function independently (e.g., lets spouse decide what kind of job he or she should have).

(b) Subordinates own needs to those of persons on whom he or she depends in order to avoid any possibility of having to rely on self (e.g., tolerates abusive spouse).

(c) Lacks self-confidence (e.g., sees self as helpless, stupid). (APA, 1980, p. 326).

In this way, diagnosing clinicians did not rely on their own meaning or interpretation for a diagnosis. Instead, they had clear guidelines for when a patient either did or did not meet criteria for a disorder. And indeed, diagnostic reliability did improve.

The DSM-III also represented a virtual explosion of disorders, jumping to a total of 256 categories, more than double the number that were in the original DSM-I. Part of that increase was a rejection of the theoretical underpinnings of the previous editions of the DSM, which incorporated many concepts embedded in Freudian thinking. Another reason for the increase was the recognition that many mental disorders started in childhood and adolescence. Finally, the use of drug therapy became a standard way of treating mental disorders about the time that the DSM-III was published, and the committees designed many of the changes to optimize choices about which drug would work best for which patients.

The DSM-III was revised to the DSM-III-R in 1987. The authors updated the criteria of several disorders. They added or deleted a handful of disorders, but the overall structure of the manual remained the same. Despite the advances in the DSM-III and DSM-III-R, they were still largely based upon expert consensus rather than on scientific evidence.

The committee that created the DSM-IV conducted exhaustive searches of the literature and data analyses regarding the validity of the disorders to be included in order to create a more scientifically informed classification system. The committee was also concerned about the proliferation of mental disorder categories that had occurred since the creation of the first DSM. It thus set stringent criteria for the addition of new categories and was very conscious of requiring convincing evidence for changing any existing categories. The DSM-IV committee paid explicit attention to the clinical utility of the manual, or how useful it would be for working clinicians. The DSM-IV underwent a text revision, which was published in 2000, but the disorders and corresponding diagnostic criteria went unchanged.

Starting with the DSM-III, diagnosis existed in a multiaxial system. In other words, each patient receives a diagnosis on five axes that each reflect different aspects of the person’s functioning. The first axis is what people would usually think of as a person’s diagnosis. The clinician records the various mental disorder categories on the first axis. Axis-II consists of the personality disorders and mental retardation. Axis-I disorders are supposedly demarcated from Axis-II because the Axis-II disorders are preexisting, long-lasting conditions that predispose one to developing an Axis-I condition. If the person has any medical conditions that may interact with or complicate his or her mental disorder, these are recorded on Axis-III. Axis-IV is a summary of all of the psychosocial stressors that are currently operative in the person’s life, such as going through a divorce, losing one’s job, and so on. These conditions are not mental disorders, but are necessary foci of attention in the context of the person’s current difficulties. The final axis is a global assessment of the person’s daily functioning (GAF) on a scale of 0 to 100, with 100 representing a perfectly adjusted and healthy individual. The multiaxial system provides a holistic means of describing the person’s difficulties and the factors that may be contributing to them.

Below, for instance, is a possible multiaxial diagnosis of Marianne, the case history of the woman working in the mortuary, using the DSM-IV:

Axis I: Dysthymic Disorder

Delusional Disorder (R/O)

Axis II:  Personality Disorder NOS

Axis III: Obesity

Axis IV: Social Isolation

Axis V:  GAF = 43

The diagnosis of dysthymic disorder on Axis I refers to Marianne’s chronic depressive style. It is as if she sees the world through blue-colored glasses—nothing fun or exciting can happen. The second Axis I diagnosis of delusional disorder is speculative. Hence, this diagnosis is followed by the symbol “R/O,” which means “rule out.” Marianne’s sudden obsession with the married subway driver possibly indicates a crazy, unrealistic belief system that this man might be interested in her. However, from the information presented, there is insufficient evidence to decide whether she has a delusional disorder or not. On Axis II, the most accurate diagnosis using the DSM-IV is that Marianne does have a personality disorder, but that her symptoms cut across a number of alternative personality disorder diagnoses including dependent personality disorder, borderline personality disorder, and schizoid personality disorder. Using the rules of the diagnostic criteria for dependent personality disorder in the DSM-IV, Marianne does not have a sufficient number to warrant that diagnosis (at least five of eight criteria). On Axis III, Marianne’s obesity would be diagnosed because this medical condition contributes to her interpersonal problems and to her psychiatric symptoms. Marianne’s extreme social isolation would be listed on Axis IV because it is directly related to her symptoms and may be a focus of treatment. The death of her mother would not be listed here since that death was too far in the past (15 years earlier) to account for her current presentation. Finally, on the GAF, Marianne was rated at 43, which means that her symptoms are serious in nature and impact her current life, but she is still able to function on some level.

DSM Issues

Reliability

In the case of Marianne, something does seem to be wrong with this woman. However, clinicians may have a hard time agreeing upon her diagnosis. We have shown this case history to a number of practicing clinical psychologists. Some diagnosed her with one personality disorder, but did not agree on which one. Others diagnosed her with several personality disorders. Still others did not use a personality disorder diagnosis at all and considered Marianne to have a delusional disorder. If clinicians cannot agree on the diagnostic term to be applied to a particular case, then each of the purposes of classification listed at the beginning of the chapter are disrupted.

The level of agreement among clinicians is termed reliability. There are several ways in which this reliability can be expressed and investigated. The most common approach examines the reliability among two or more clinicians regarding the same case, also called interrater reliability. To understand the issues regarding interrater reliability, however, one first needs to understand a few things about the diagnostic process and how the information used to form a diagnosis is gathered. In the early days of the DSM-I and DSM-II, a clinician would meet with a client for an initial interview and, based on that interview, would assign that patient a diagnosis. However, within that interview, the clinician would ask whatever questions he or she considered important or relevant. Another clinician may consider different types of information much more informative, and thus have a very different set of information upon which to base a diagnosis. For Marianne’s case, one clinician might focus on her day-to-day activities, or lack thereof, and come to a diagnosis of dysthymic disorder. Another might focus on Marianne’s isolation and lack of friends, which suggests a personality disorder diagnosis. Both pieces of information are true of Marianne, but by focusing on what the clinician considers important, other pieces of information might be ignored.

Thus, with the DSM-III and beyond, clinicians used semistructured interviews to increase the reliability of diagnosis. A semistructured interview consists of a series of questions regarding the presence or absence of the diagnostic criteria for each disorder. The interview covers all the areas of psychopathology described in the DSM, and hence ensures that the interview is comprehensive. The interview is termed “semistructured” because the clinician is still free to ask follow-up questions to those listed, but at a minimum must cover the questions in the interview. Thus, by using semistructured interviews, the reliability of diagnosis among different clinicians is increased because they are confronted with similar sets of information.

However, the problem with semistructured interviews as the gold standard of diagnostic process is exactly the problem they were created to avoid. Because the interview is structured to follow the diagnostic criteria of the DSM, it ignores other potential areas of concern that are not included in the DSM. For instance, most semistructured interviews focus on current symptoms. Such an interview may miss the fact that Marianne ended up working in a mortuary after the death of her mother. This piece of information speaks volumes about Marianne’s interpersonal style and dependency issues, and helps predict how she will respond in future situations, such as her failed relationship with the subway driver.

Validity

Whereas reliability is the consistency of the score, validity is the meaningfulness of the score. For example, 10 clinicians could ask Marianne what her favorite food is, and she would respond the same to all 10 clinicians. This piece of information would be highly reliable. However, such information is not valid because it is not clinically useful. Knowing her favorite food tells us nothing about her psychopathology. Thus, just because a system is reliable, it is not necessarily valid.

There are several types of validity. Content validity is the degree to which the definition of the diagnostic category represents the diagnostic concept. For example, do the diagnostic criteria for depression represent all the possible symptoms of depressed individuals? It is difficult to say, because the categories of psychopathology are rarely discrete (i.e., it is rare for a person to meet criteria for only one disorder). The problem of diagnostic overlap will be discussed more later, but for now, it creates a problem in ensuring that all the symptoms of a type of psychopathology are adequately represented in the criteria. Many individuals who meet the criteria for a diagnosis of depression also have marked symptoms of anxiety. Is that evidence for a separate anxiety disorder, or should anxiety be considered a part of the concept of depression?

A second type of validity is criterion validity. Within the context of classification, criterion validity is the extent to which a category is meaningfully related to certain outcome variables like the course of the disorder, treatment, life adjustment, and functioning. To consider just the case of treatment, it is difficult to establish criterion validity for a diagnostic category because treatment effects are rarely specific. One type of treatment usually works for many if not all types of disorder, and the treatment usually improves several areas of the person’s life, not just those directly relevant to the disorder.

A third type of validity is construct validity, which is the meaningfulness of the definition of the diagnostic concept. For example, how well does the concept of schizophrenia map onto the phenomena of the world? A famous clinical psychologist named Robert Kendell (1975) spoke of a classification as “carving nature at the joints” (p. 65). Construct validity can be thought of as the success of a concept in capturing the nature of the world. In that sense, it is also the hardest type of validity to achieve, and the most hotly debated. For instance, the argument has been made (and returns from time to time) that there is no such thing as a mental disorder, but only “ways of being” that society values or devalues. For example, in some cultures, the types of behaviors usually attributed to schizophrenia such as hearing voices, unusual beliefs about the world, and so on would be highly prized in the role of a medicine man or spiritual leader. The means by which a disorder is usually defined as a concept is through specific symptoms that seem to go together. This collection of symptoms is termed a syndrome. Through studying the syndrome, various patterns emerge, such as a similar course to the disorder or response to treatment (i.e., criterion validity). Eventually, a common etiology or cause is discovered that explains the disorder. However, very few mental disorders have an established “cause.” There are many good arguments as to why such a simplistic model of mental disorder concepts as currently exists in the DSM may fail to capture the true nature of mental disorders.

Comorbidity

One issue that has currently confounded the field is the amount of diagnostic overlap that exists among mental disorder categories. This overlap is termed comorbidity. Comorbidity creates several problems for mental disorder classification and the DSMs. A recent large national survey found that diagnostic overlap occurs in 45 percent of cases (Kessler, Chiu, Demler, & Walters, 2005). Another, smaller study at one hospital with patients with personality disorders found that slightly over 25 percent of the sample met the diagnostic criteria for 5 of the 11 personality disorders (Blashfield, McElroy, Pfohl, & Blum, 1994). In that study, there was even one patient who met the criteria for all 11 personality disorders!

What these studies show is that, if a person meets criteria for one disorder, most likely that same patient will meet criteria for several other disorders, too. One of the basic assumptions of the categorical system of the DSM is that the disorders are relatively discrete or separable. However, this assumption may be faulty, especially given the amount of overlap that seems to exist.

As we have already noted, treatment for mental disorders tends to be nonspecific. If a treatment works for one disorder, it is likely to work for most disorders. Researchers who study medications and psychological therapies are searching for empirically supported treatments, or treatments that research has shown to be effective. However, the model of scientific investigation that examines these treatments demands homogeneous groups of patients. A treatment is shown to be effective for a particular disorder, not in general. For instance, a psychiatric drug can be marketed and labeled as a treatment for only one particular disorder, even though its effects are much more general. Thus, the current classification system seems to be counterproductive to the study of treatments for disorders because it does not “carve nature at the joints” when it comes to how these disorders are treated.

Comorbidity also confounds research on mental disorders in general. The current scientific paradigm is based upon ruling out alternative explanations for a finding. Thus, when a researcher is studying a particular disorder, that researcher needs to ensure that the effect found in the study could come about only through the person’s having that particular disorder. The researcher wants to find groups of people to study who have the disorder of interest but not any other disorders. If the participants had disorders other than that under study, the effects of the study could be explained by the presence of other disorders. Of course, the problem is that most people who do have one mental disorder also have other disorders. Thus, finding research participants who have only one disorder is difficult because people who meet the diagnostic criteria for only one mental disorder are relatively rare. As a result, findings from research about these relatively unusual individuals are hard to generalize to most people who have the disorder.

An Alternative Approach To And Future Directions For The DSM

The DSM classification of mental disorders is based on a categorical approach. A categorical system is the “traditional method of organizing and transmitting information in everyday life and has been the fundamental approach used in all systems of medical diagnosis” (APA, 2000, p. xxxi). This approach suggests that a disorder is its own unique entity with clear boundaries that contain the characteristics of that disorder. As such, groups of patients sharing the same symptoms should be given the same diagnosis, and these groups should be homogeneous and mutually exclusive.

For example, delusional disorder (a possible diagnosis for our fictitious patient, Marianne) is defined by four symptoms of which all four symptoms must be present for a diagnosis. Within a categorical approach, if Marianne fits neatly into the delusional category, assuming she exhibits the required four symptoms, then her psycho-pathology presentation should be very similar to that of other patients who meet criteria for delusional disorder. To use another example, it is likely that Marianne might have a personality disorder or, in fact, several personality disorder diagnoses. In addition to dependent personality disorder, another personality disorder diagnosis that might be representative of Marianne’s presentation is borderline personality disorder. This disorder is defined by nine distinct criteria of which only five are necessary for a diagnosis. Again, a categorical approach assumes that groups are homogeneous, but in the case of borderline personality disorder, two individuals could potentially have two completely different symptom presentations but fall under the same disorder category. The DSM recognizes the limitations of the categorical approach and advises mental health professionals using this system to be aware that “individuals sharing a diagnosis are likely to be heterogeneous even in regard to the defining features of the diagnosis and that boundary cases will be difficult to diagnose in any but a probabilistic fashion” (APA,2000, p. xxxi).

Primarily due to “boundary cases” and comorbidity, where a patient meets the criteria of more than one diagnostic category, an alternative to the categorical approach has emerged. Several researchers have suggested that a dimensional system better represents the organization of mental disorders and should replace the DSM’s categorical system (Samuel & Widiger, 2006; Trull & Durrett, 2005). A dimensional approach inherently provides more descriptive and precise information. With a categorical approach, diagnostic decisions are based on a dichotomized arrangement—either you fall into a certain category or you do not. Many medical diagnoses are based on this dichotomy. A patient either has HIV or does not; a patient has strep throat or not. However, a categorical approach does not provide any additional information to knowing anything more about the individual. For instance, consider intelligence. It is not useful to categorize this construct by saying someone is intelligent or not intelligent. It would not be sufficient to determine school placement, employment decisions, or learning disability accommodations based on a dichotomized division of intelligence. Rather, a more functional approach would be to describe an individual’s intelligence on a dimensional scale (i.e., comparing an intelligence score of 108 to a score of 79), resulting in more specific and practical information to help determine decisions. This same case can be made in regard to mental disorders. A dimensional approach for mental disorders may provide much more information to clinicians than what a simple, categorical diagnosis does.

The personality disorder section of the DSM-IV has received more attention and research effort in embracing the dimensional system. However, other groups of disorders have also received consideration for a dimensional approach, such as mood disorders, anxiety disorders, psychotic disorders, and childhood disorders. An example of a dimensional approach with personality disorders will be considered below, using Marianne as the patient, because more research has been devoted to personality disorders for the possible transition from a categorical organization to a dimensional structure.

A well-known dimensional organization of personality characteristics is the five-factor model (FFM; Costa & McCrae, 1992). This dimensional perspective considers the degree of expression of personality traits on five domains with the following names: neuroticism, extraversion, openness to experience, agreeableness, and conscientiousness. The five domains are further divided into six facets for each domain (a total of 30 facets). For example, the neuroticism domain consists of personality traits related to anxious-ness, angry hostility, depressiveness, self-consciousness, impulsivity, and vulnerability. The FFM was developed to supply a comprehensive description of an individual’s personality functioning by providing the clinician with information on both adaptive and maladaptive personality traits.

In the case of Marianne, mental health professionals using a dimensional system would have available to them the ratings on each of the facets for all the domains. These ratings would be based on the degree to which Marianne exhibits such traits. For example, on the facet of gregariousness (found under the extraversion domain), Marianne would receive a low rating, such as a one or two on a five-point scale, suggesting that she is lonely, withdrawn, and avoidant of others. Once this rating system is applied to all the FFM facets, the clinician is presented with a complete clinical picture of Marianne’s functioning on numerous traits. Consequently, a more comprehensive diagnostic profile is generated, as opposed to only a diagnostic label.

The FFM is just one of many dimensional models that attempt to classify mental disorders. What most dimensional models have in common are their efforts to alleviate the problems presented by the categorical model. Using a dimensional approach, the problem of comorbidity becomes irrelevant because clinicians do not assign patients exclusively to one category, but rather describe them based on several dimensional ratings, all of which make up the “diagnostic label.” The problem of cases that fall between the boundaries of one categorical group and another categorical group ceases to exist. With a dimensional approach, patients are not forced to fit neatly into one category or another. There are no gaps in a dimensional system.

A dimensional approach also provides a richer, more clinically useful profile of patients. As mentioned before, if two individuals are labeled as having borderline personality disorder, these labels offer no further information on the qualitative differences that may exist between the two individuals. It cannot be assumed that they share similar presentations just because they share the same diagnosis (the categorical assumption of homogeneous groups). Borderline personality disorder has the characteristic of potentially having two patients share only one criterion out of the five criteria necessary for a diagnosis. Assigning such a label does not speak to what behaviors are present or to what degree of severity the symptoms are expressed. A dimensional model communicates more clinical information because it includes ratings on specific attributes, especially on attributes that fail to be recognized by the criteria stipulations of the categorical system.

However, the dimensional system is not without its own problems. These problems are the complexity of such a system and the fact that most clinicians are unfamiliar with a dimensional system. Mental health professionals are far more familiar with the categorical names of mental disorders because their training and practice have revolved around the DSM. Further, no consensus has been reached on what dimensions best represent the classification of psychopathology. The FFM is just one approach, but several alternatives are available that make a compelling case for three, seven, and even 16 dimensions. The categorical model also provides the convenience of offering a simple diagnostic label to describe a patient, even though this convenience contains the inherent limitations of categories. With a dimensional approach, a clinician is faced with trying to map the patient on a complex grid with a number of possibly relevant dimensions.

Summary

This research-paper started with a discussion of a case history about Marianne. The case history is taken from a 1984 German movie entitled Zuckerbaby (Sugarbaby). The movie has a cult following, and its director is well known to movie buffs who follow European movies. Like many movies, this one is built around a love story between a man and a woman. However, Zuckerbaby is quite different from a conventional love story seen in most American theaters. The movie was shot in a major city in Germany and has English subtitles. The main character in the movie, Marianne, is a late 30-ish, obese, “unattractive” woman wholly unlike the typically pretty or even beautiful women who star in most romantic movies. Even more off-putting to the observer is that the male in the movie is a tall, athletic, 23-year-old married man. To add to its unconventional style, the movie is shot through metallic blue and/or metallic pink lenses, which lend an unreal, “subway” feel to all of the settings in the movie. Finally, at emotional points in the movie, the camera swings on a boom, with its oscillations increasing as the emotionality of the scene increases.

Despite the weirdness of this movie, what comes through is how the viewer gradually begins to care about the characters and even to identify with their loneliness, their need for love, and their humanity. In the words of a famous American psychiatrist, what this movie represents is that “everyone is much more simply human than otherwise” (Sullivan, 1953, p. 32).

We have performed research studies using Marianne as a case history, asking clinicians to diagnose her (e.g., Burgess & Blashfield, 2006). Psychiatrists and psychologists consistently seem to agree that Marianne has some type of personality disorder, but exactly which personality disorder is uncertain. In one of our studies, the most common diagnosis for Marianne was given by less than 20 percent of the sample of clinicians. Clinicians agree that there is something unusual about her, but they cannot classify her.

Perhaps the problem in diagnosing Marianne as a case history is the same problem that the viewer has when watching the movie Zuckerbaby. Despite all of the structural elements that work against doing so, we identify with her. She is like us. She is what we all see in ourselves at 4 a.m. when we are alone in the world and everything else has ceased to exist. Like Marianne, we are depressed, anxious, paranoid about the intentions of others; we think strange thoughts, and we wonder what is real versus what is unreal. In other words, what fascinates all of us about psychopathology is that all of us manifest abnormal thoughts, behaviors, and emotions at various times in our life. To some extent, the abnormal is normal.

The DSM is the currently accepted authoritative reference source that categorizes what being abnormal means. The DSMs, despite their authoritative status, are controversial. Although these are the best attempts by current researchers and clinicians in the field to organize our understanding of abnormal behavior, the DSMs, like any products of committees, have flaws and limitations. When you study abnormal psychology, you should remember that the DSMs do not contain inviolable truths. They contain a particular committee’s interpretation of what is the best information currently available about psychopathology. More important, you should remember that if the abnormal is normal, what does being abnormal mean?

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