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1.9: Classification and Labeling

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    Learning Objectives
    • Discuss arguments and objections surrounding the DSM classification system
    • Describe problems associated with classification and labeling

    Advantages and Disadvantages of the DSM‐5 Classification System

    With any system of classification like DSM‐5, there will always be strengths and weaknesses. One of the major strengths of the DSM system is the wide acceptance and use of the system. Mental health professionals in the United States routinely utilize diagnostic systems in their work if for no other reason than to allow their clients to receive treatment in hospitals and reimbursement from health care providers. Each category of disorder has a numeric code taken from the ICD coding system, used for health service (including insurance) administrative purposes.

    The limitations of the DSM system are reflected in the terminology related to diagnosis itself. Since the DSM-3, the goal was to improve the uniformity and validity of psychiatric diagnosis in the wake of a number of critiques, including the famous Rosenhan experiment (see box below). There was also felt a need to standardize diagnostic practices within the United States and with other countries, after research showed that psychiatric diagnoses differed between Europe and the United States.[1]

    A closer look: The Rosenhan Experiment

    The Rosenhan experiment was carried out by David Rosenhan, a Stanford University professor, and published by the journal Science in 1973 under the title “On Being Sane in Insane Places.” It was an experiment conducted to determine the reliability and validity of psychiatric diagnosis. The experimenters feigned hallucinations to enter psychiatric hospitals, and acted normally afterwards. They were diagnosed with psychiatric disorders and were given antipsychotic drugs.

    The study was c onsidered an important and influential criticism of psychiatric diagnosis. It has been argued that the experiment was fabricated; nonetheless, the study concluded, “it is clear that we cannot distinguish the sane from the insane in psychiatric hospitals,” and it also illustrated the dangers of dehumanization and labeling in psychiatric institutions. It suggested that the use of community mental health facilities that concentrated on specific problems and behaviors rather than psychiatric labels might be a solution, and recommended education to make psychiatric workers more aware of the social psychology of their facilities.

    Here is a seven-minute video summing up the study.

    Reliability and Validity

    The revisions and refinements in the DSM classification system have been largely driven by the need to improve reliability and validity. Reliability measures how consistent a diagnosis is and how reliably the categories can be judged. Validity looks at how accurate the diagnosis is and how valid the categories are in the sense of discriminating among disorders that have distinctive etiologies and possibly require different treatments.

    Reliability Vs. Validity

    Query \(\PageIndex{1}\)

    To be useful, any diagnostic system must demonstrate reliability and validity. The revisions of the DSM from the third edition forward have been mainly concerned with diagnostic reliability—the degree to which different diagnosticians agree on a diagnosis. If clinicians and researchers frequently disagree about the diagnosis of a patient, then research into the causes and effective treatments of those disorders cannot advance. To be considered reliable, or consistent, different evaluators using the system should arrive at the same diagnoses when they evaluate the same people. For example, a diagnosis of major depressive disorder, a common mental illness, had a poor reliability kappa statistic of 0.28, indicating that clinicians frequently disagreed on diagnosing this disorder in the same patients. The most reliable diagnosis was major neurocognitive disorder, with a kappa of 0.78.[2]

    Critics assert, for example, that many DSM-5 revisions or additions lack empirical support; inter-raterreliability, or the degree of agreement among raters, is low for many disorders; several sections contain poorly written, confusing, or contradictory information; and the psychiatric drug industry unduly influenced the manual’s content (many DSM-5 workgroup participants had ties to pharmaceutical companies).footnote]Welch, Steven; Klassen, Cherisse; Borisova, Oxana; Clothier, Holly (2013). “The DSM-5 controversies: How should psychologists respond?”. Canadian Psychology. 54(3): 166–175. doi:10.1037/a0033841[/footnote]

    Other critics also believe the DSM needs to become more sensitive to the importance of cultural and ethnic factors in diagnostic assessment. They encourage us to consider and understand that the symptoms or problem behaviors included as diagnostic criteria in the DSM were largely determined by a consensus of mostly U.S.-trained psychiatrists, psychologists, and social workers. Imagine that the American Psychiatric Association had asked Asian-trained or Latin American–trained professionals to develop their diagnostic manual? Might there might have been different diagnostic criteria or even different diagnostic categories? [5]

    Overall, the bulk of limitations of the DSM system listed so far are related to the diagnostic system in general. It is worthwhile to be alert to the criticisms of the DSM system, particularly since they serve as a reminder that mental health professionals aim to help the individual and not the disorder. Furthermore, the DSM system has been useful to insurance companies who adopt its use to establish coverage for certain clinical disorders, and has been helpful in allowing researchers and clinicians to have a common language with which to discuss clients.

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    Differences between Categorical and Dimensional Understanding of Behavior

    Both the DSM and ICD systems represent a categorical approach to the description of mental disorders. As the name implies, a categorical approach attempts to categorize mental disorders into distinct diagnoses. The categorical approach is based on the idea that a person either meets criteria for a specific disorder or they do not. Traditional categorical models of classification, which are based on the presence or absence of symptoms, do not take into account levels of expression of a characteristic or the presence of any underlying dimension. This conceptualization allows a mental health professional to make a dichotomous decision (i.e., yes, the person meets criteria or no, the person does not meet criteria for that disorder). A dimension refers to a continuum on which an individual can have various levels of a characteristic, in contrast to the dichotomous categorical approach in which an individual does or does not possess a characteristic.

    The most important change in DSM-5 was the inclusion of dimensions in diagnoses; for example, how severely ill is a patient with schizophrenia or depression? The dimensional approach focuses on varying levels of different behaviors that a person exhibits, rather than whether or not a person meets criteria for a particular disorder. The dimensional approach is also included in Section III of the DSM-5 (“Emerging Measures and Models”). This section includes assessment measures and diagnoses not considered well-established enough to be part of the main system. For example, an “Alternative DSM-5 Model for Personality Disorders” is described.[7] The decision to retain the old DSM-4 categorical model for personality disorders in DSM-5 was controversial (currently the ten personality disorders are grouped into three general categories), and efforts continue to persuade the American Psychiatric Association to replace it with the dimensional model in DSM 5.1. [8]

    Regardless of whether you use a categorical or dimensional approach to understand a person’s functioning, it is crucial to remember that behavior can change over time.

    Problems Associated with Classification and Labeling

    Finally, but probably most importantly, any diagnostic system such as the DSM system allows for individuals to be labeled for behavior that may or may not be an important part of their character. Labeling occurs when information about a person’s diagnostic classification is communicated in a negative manner that leads to stigma for the individual with a mental disorder.

    The “Mentally Ill”

    The social construction of deviant behavior plays an important role in the labeling process that occurs in society. This process involves not only the labeling of criminally deviant behavior, which is behavior that does not fit socially constructed norms, but also labeling that which reflects stereotyped or stigmatized behavior of the “mentally ill.”

    Labeling theory posits that self-identity and the behavior of individuals may be determined or influenced by the terms used to describe or classify them. It is associated with the concepts of self-fulfilling prophecy and stereotyping. However, the label of “mentally ill“ may help a person seek help, for example, psychotherapy or medication. Labels, while they can be stigmatizing, can also lead those who bear them down the road to proper treatment and (hopefully) recovery. If one believes that “being mentally ill” is more than just believing one should fulfill a set of diagnostic criteria, then one would probably also agree that there are some who are labeled “mentally ill” who need help. It has been claimed that this could not happen if there were no way to categorize (and therefore label) them, although there are actually plenty of approaches to these phenomena that don’t use categorical classifications and diagnostic terms, such as spectrum or continuum models. Here, people vary along different dimensions, and everyone falls at different points on each dimension.

    The issue at stake is that DSM-5 may lead to the increasingly widespread “medicalization” of psychology. It is suggested that – also due to its impact via the social media – DSM-5 is likely to turn into a true “social representation” (Moscovici et al., 2001) with the power to strongly influence clinical practice, pushing it in the direction of the large-scale prescription of drugs.[12] Allen Frances, Chair of the DSM-IV Task Force, came to be a remarkably prolific and vocal critic of the proposed changes that came out in the DSM-5. In a BMJ editorial, he described the ‘grave’ consequences of ‘false positive epidemics’ of disorders that would be constituted through inappropriate usage of new diagnostic entities; in so doing, DSM-5 would ‘expand the territory of mental disorder and thin the ranks of the normal’. In other words, it would help to further ‘medicalize’ society.[13]

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    Glossary

    categorical approach: attempts to categorize mental disorders into distinct diagnoses

    diagnostic reliability: the degree to which different diagnosticians agree on a diagnosis; consistency and reproducibility of a given result

    dimension: refers to a continuum on which an individual can have various levels of a characteristic

    inter-raterreliability: the degree of agreement among raters

    labeling: occurs when information about a person’s diagnostic classification is communicated in a negative manner that leads to stigma for the individual with a mental disorder.

    1. Cooper, JE; Kendell, RE; Gurland, BJ; Sartorius, N; Farkas, T (April 1969). "Cross-national study of diagnosis of the mental disorders: some results from the first comparative investigation". The American Journal of Psychiatry. 125 (10 Suppl): 21–9. doi:10.1176/ajp.125.10s.21. PMID 5774702. Archived from the original on 2010-08-24. ↵
    2. Freedman, Robert; Lewis, David A.; Michels, Robert; Pine, Daniel S.; Schultz, Susan K.; Tamminga, Carol A.; Gabbard, Glen O.; Gau, Susan Shur-Fen; Javitt, Daniel C.; Oquendo, Maria A.; Shrout, Patrick E.; Vieta, Eduard; Yager, Joel (January 2013). "The Initial Field Trials of DSM-5: New Blooms and Old Thorns." American Journal of Psychiatry. 170 (1): 1–5. doi:10.1176/appi.ajp.2012.12091189. PMID 23288382. Archived from the original on 2013-01-15. ↵
    3. Surís, A., Holliday, R., & North, C. S. (2016). The Evolution of the Classification of Psychiatric Disorders. Behavioral sciences (Basel, Switzerland), 6(1), 5. https://doi.org/10.3390/bs6010005↵
    4. Kendell, R; Jablensky, A (2003). "Distinguishing between the validity and utility of psychiatric diagnoses". The American Journal of Psychiatry. 160 (1): 4–12. doi:10.1176/appi.ajp.160.1.4. PMID 12505793 ↵
    5. Alarcón, R. D., Becker, A. E., Lewis-Fernández, R., Like, R. C., Desai, P., Foulks, E., . . . Primm, A. (2009). Issues for DSM-5: The role of culture in psychiatric diagnosis. The Journal of Nervous and Mental Disease, 197, 559–660. doi:10.1097/NMD.0b013e3181b0cbff ↵
    6. Surís, A.; Holliday, R.; North, C.S. The Evolution of the Classification of Psychiatric Disorders. Behav. Sci. 2016, 6, 5. ↵
    7. American Psychiatric Association (2013). Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. World Psychiatry. 14. pp. 234–236. ↵
    8. Skodol, Andrew E.; Leslie C. Morey; Donna S. Bender; John M. Oldham (2013). "The ironic fate of the personality disorders in DSM-5." Personality Disorders: Theory, Research, and Treatment. 4 (4): 342–349. ↵
    9. Weiner, Irving B. (2003). Handbook of Psychology, Volume 11, Forensic Psychology. 11. Hoboken, NJ: Wiley. pp. 120–121. ↵
    10. Scheff, Thomas J. 1984. Being Mentally Ill (2nd ed.). Piscataway: Aldine Transaction. ↵
    11. Gove, Walter R. (1975). Labelling of Deviance: Evaluating a Perspective. Hoboken: John Wiley & Sons Inc. ↵
    12. Castiglioni, M., & Laudisa, F. (2015). Toward psychiatry as a 'human' science of mind. The case of depressive disorders in DSM-5. Frontiers in psychology, 5, 1517. https://doi.org/10.3389/fpsyg.2014.01517↵
    13. Pickersgill, MD (2014). Debating DSM-5: diagnosis and the sociology of critique. Journal of Medical Ethics. 40:521-525. ↵
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