Handbook of Psychology, Clinical Psychology

By Irving B. Weiner, George Stricker and Thomas A. Widiger

Psychology is of interest to academics from many fields, as well as to the thousands of academic and clinical psychologists and general public who can't help but be interested in learning more about why humans think and behave as they do. This award-winning twelve-volume reference covers every aspect of the ever-fascinating discipline of psychology and represents the most current knowledge in the field. This ten-year revision now covers discoveries based in neuroscience, clinical psychology's new interest in evidence-based practice and mindfulness, and new findings in social, developmental, and forensic psychology.

• Language: English
• Publisher: Wiley
• Release date: Oct 15, 2012
• ISBN: 9781118404454

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Editorial Board

Volume 1

History of Psychology

Donald K. Freedheim, PhD

Case Western Reserve University

Cleveland, Ohio

Volume 2

Research Methods in Psychology

John A. Schinka, PhD

University of South Florida

Tampa, Florida

Wayne F. Velicer, PhD

University of Rhode Island

Kingston, Rhode Island

Volume 3

Behavioral Neuroscience

Randy J. Nelson, PhD

Ohio State University

Columbus, Ohio

Sheri J. Y. Mizumori, PhD

University of Washington

Seattle, Washington

Volume 4

Experimental Psychology

Alice F. Healy, PhD

University of Colorado

Boulder, Colorado

Robert W. Proctor, PhD

Purdue University

West Lafayette, Indiana

Volume 5

Personality and Social Psychology

Howard Tennen, PhD

University of Connecticut Health Center

Farmington, Connecticut

Jerry Suls, PhD

University of Iowa

Iowa City, Iowa

Volume 6

Developmental Psychology

Richard M. Lerner, PhD

M. Ann Easterbrooks, PhD

Jayanthi Mistry, PhD

Tufts University

Medford, Massachusetts

Volume 7

Educational Psychology

William M. Reynolds, PhD

Humboldt State University

Arcata, California

Gloria E. Miller, PhD

University of Denver

Denver, Colorado

Volume 8

Clinical Psychology

George Stricker, PhD

Argosy University DC

Arlington, Virginia

Thomas A. Widiger, PhD

University of Kentucky

Lexington, Kentucky

Volume 9

Health Psychology

Arthur M. Nezu, PhD

Christine Maguth Nezu, PhD

Pamela A. Geller, PhD

Drexel University

Philadelphia, Pennsylvania

Volume 10

Assessment Psychology

John R. Graham, PhD

Kent State University

Kent, Ohio

Jack A. Naglieri, PhD

University of Virginia

Charlottesville, Virginia

Volume 11

Forensic Psychology

Randy K. Otto, PhD

University of South Florida

Tampa, Florida

Volume 12

Industrial and Organizational Psychology

Neal W. Schmitt, PhD

Michigan State University

East Lansing, Michigan

Scott Highhouse, PhD

Bowling Green State University

Bowling Green, Ohio

Handbook of Psychology Preface

The first edition of the 12-volume Handbook of Psychology was published in 2003 to provide a comprehensive overview of the current status and anticipated future directions of basic and applied psychology and to serve as a reference source and textbook for the ensuing decade. With 10 years having elapsed, and psychological knowledge and applications continuing to expand, the time has come for this second edition to appear. In addition to well-referenced updating of the first edition content, this second edition of the Handbook reflects the fresh perspectives of some new volume editors, chapter authors, and subject areas. However, the conceptualization and organization of the Handbook, as stated next, remain the same.

Psychologists commonly regard their discipline as the science of behavior, and the pursuits of behavioral scientists range from the natural sciences to the social sciences and embrace a wide variety of objects of investigation. Some psychologists have more in common with biologists than with most other psychologists, and some have more in common with sociologists than with most of their psychological colleagues. Some psychologists are interested primarily in the behavior of animals, some in the behavior of people, and others in the behavior of organizations. These and other dimensions of difference among psychological scientists are matched by equal if not greater heterogeneity among psychological practitioners, who apply a vast array of methods in many different settings to achieve highly varied purposes. This 12-volume Handbook of Psychology captures the breadth and diversity of psychology and encompasses interests and concerns shared by psychologists in all branches of the field. To this end, leading national and international scholars and practitioners have collaborated to produce 301 authoritative and detailed chapters covering all fundamental facets of the discipline.

Two unifying threads run through the science of behavior. The first is a common history rooted in conceptual and empirical approaches to understanding the nature of behavior. The specific histories of all specialty areas in psychology trace their origins to the formulations of the classical philosophers and the early experimentalists, and appreciation for the historical evolution of psychology in all of its variations transcends identifying oneself as a particular kind of psychologist. Accordingly, Volume 1 in the Handbook, again edited by Donald Freedheim, is devoted to the History of Psychology as it emerged in many areas of scientific study and applied technology.

A second unifying thread in psychology is a commitment to the development and utilization of research methods suitable for collecting and analyzing behavioral data. With attention both to specific procedures and to their application in particular settings, Volume 2, again edited by John Schinka and Wayne Velicer, addresses Research Methods in Psychology.

Volumes 3 through 7 of the Handbook present the substantive content of psychological knowledge in five areas of study. Volume 3, which addressed Biological Psychology in the first edition, has in light of developments in the field been retitled in the second edition to cover Behavioral Neuroscience. Randy Nelson continues as editor of this volume and is joined by Sheri Mizumori as a new co-editor. Volume 4 concerns Experimental Psychology and is again edited by Alice Healy and Robert Proctor. Volume 5 on Personality and Social Psychology has been reorganized by two new co-editors, Howard Tennen and Jerry Suls. Volume 6 on Developmental Psychology is again edited by Richard Lerner, Ann Easterbrooks, and Jayanthi Mistry. William Reynolds and Gloria Miller continue as co-editors of Volume 7 on Educational Psychology.

Volumes 8 through 12 address the application of psychological knowledge in five broad areas of professional practice. Thomas Widiger and George Stricker continue as co-editors of Volume 8 on Clinical Psychology. Volume 9 on Health Psychology is again co-edited by Arthur Nezu, Christine Nezu, and Pamela Geller. Continuing to co-edit Volume 10 on Assessment Psychology are John Graham and Jack Naglieri. Randy Otto joins the Editorial Board as the new editor of Volume 11 on Forensic Psychology. Also joining the Editorial Board are two new co-editors, Neal Schmitt and Scott Highhouse, who have reorganized Volume 12 on Industrial and Organizational Psychology.

The Handbook of Psychology was prepared to educate and inform readers about the present state of psychological knowledge and about anticipated advances in behavioral science research and practice. To this end, the Handbook volumes address the needs and interests of three groups. First, for graduate students in behavioral science, the volumes provide advanced instruction in the basic concepts and methods that define the fields they cover, together with a review of current knowledge, core literature, and likely future directions. Second, in addition to serving as graduate textbooks, the volumes offer professional psychologists an opportunity to read and contemplate the views of distinguished colleagues concerning the central thrusts of research and the leading edges of practice in their respective fields. Third, for psychologists seeking to become conversant with fields outside their own specialty and for persons outside of psychology seeking information about psychological matters, the Handbook volumes serve as a reference source for expanding their knowledge and directing them to additional sources in the literature.

The preparation of this Handbook was made possible by the diligence and scholarly sophistication of 24 volume editors and co-editors who constituted the Editorial Board. As Editor-in-Chief, I want to thank each of these colleagues for the pleasure of their collaboration in this project. I compliment them for having recruited an outstanding cast of contributors to their volumes and then working closely with these authors to achieve chapters that will stand each in their own right as valuable contributions to the literature. Finally, I would like to thank Brittany White for her exemplary work as my administrator for our manuscript management system, and the editorial staff of John Wiley & Sons for encouraging and helping bring to fruition this second edition of the Handbook, particularly Patricia Rossi, Executive Editor, and Kara Borbely, Editorial Program Coordinator.

Irving B. Weiner

Tampa, Florida

Volume Preface

This eighth volume of the Handbook of Psychology is devoted to the primary concerns of clinical psychologists with understanding mental, emotional, and behavioral disorders; with developing and applying psychological techniques for alleviating these disorders; and with issues of importance to the profession of clinical psychology. We provide in this second edition of our volume an updated presentation of what is currently known about the origins, characteristics, and treatment of psychopathology, as well as likely future advances in this knowledge. The first 10 chapters address the diagnosis, etiology, course, and pathology of the major psychological disorders; the next 11 chapters describe psychotherapeutic approaches commonly used in treating these disorders; and the concluding four chapters discuss several key professional issues in clinical psychology. It should be noted that there are no chapters dealing with assessment, which is a core component of clinical psychology, because psychological assessment is covered extensively in Volume 10 of the Handbook (Assessment Psychology). Similarly, each of the chapters in the present volume incorporates attention to research and historical developments, but there is no separate chapter on clinical research methods, which are discussed in Volume 2 of the Handbook (Research Methods in Psychology), or on the history of clinical psychology, which is reviewed in Volume 1 (History of Psychology).

The first chapter, by Thomas A. Widiger and Cristina Crego, is devoted to the classification and diagnosis of psychopathology. As they indicate, a common language for describing the problems of the mind is necessary in clinical research and practice. The predominant taxonomy of psychopathology is provided by the American Psychiatric Association's (2000) Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR). There is much to applaud with respect to the value, utility, and validity of this diagnostic manual, but there is also much that is potentially quite problematic. An updated version of this chapter is particularly timely given that the American Psychiatric Association is currently revising its manual (to become DSM-5). The process and content of this effort has been relatively controversial.

Eric J. Mash and David A. Wolfe follow with an updated version of their chapter on the major domains of child psychopathology. Beginning with disorders of childhood is an obvious starting point for understanding the development of psychopathology. However, as indicated by Mash and Wolfe, current knowledge of disorders of childhood and adolescence are hindered by a lack of child-specific developmental theories, and the inherent conceptual and research complexities associated with studying children, which may explain why there are fewer evidence based treatments for children than for adults. Despite these caveats, tremendous advances have been made over the last decade. New conceptual frameworks and research methods have greatly enhanced our understanding of childhood disorders, as well as our ability to help children with these problems. Also noteworthy has been an increase in interdisciplinary research and integration of science into clinical practice. All of these advances are articulated within this updated version.

Eating disorders were classified as a disorder of childhood and adolescence in earlier diagnostic nomenclatures, but it is now recognized that they can have an onset into adulthood. Eating disorders have been recognized since the beginning of medicine and are among the more frequently diagnosed and treated mental disorders. Howard Steiger, Kenneth R. Bruce, and Mimi Bruce update their chapter on eating disorders. They had included not only anorexia nervosa and bulimia within the original version of this chapter, but also binge eating disorder, which appears likely to be approved for inclusion within DSM-5. They provide in their chapter a compelling integrative conceptualization that considers developmental, cognitive, social, dynamic, and neurophysiological contributions to the etiology and pathology of eating disorders.

Personality disorders were placed on a separate, distinct axis for diagnosis in the third edition of the DSM-IV-TR (American Psychiatric Association, 2000) in recognition of their prevalence and their contribution to the course and treatment of other mental disorders. Timothy J. Trull, Ryan J. Carpenter, and Thomas A. Widiger cover in their chapter not only what is largely known and understood regarding disorders of personality but also the controversies that bedevil this section of the diagnostic manual. An updated version of this chapter is very timely given the major changes that have been proposed and are likely to occur with DSM-5, including the deletion of up to half of the diagnoses and a shift toward a dimensional model of classification that they had recommended in the first edition of this book.

Mood and anxiety disorders are the most frequent mental disorders and are probably the most frequently treated by clinical psychologists. As suggested by Constance Hammen and Danielle Keenan-Miller, depressive disorders are so ubiquitous that they have been called the common cold of psychological disorders. However, Hammen documents well in her thoroughly updated chapter that prevalence does not imply simplicity, and she again emphasizes the importance of considering etiology and pathology from divergent perspectives, including the cognitive, interpersonal, developmental, and neurobiological.

Kaitlin P. Gallo, Johanna Thompson-Hollands, Donna B. Pincus, and David H. Barlow provide a comparably sophisticated overview of the etiology, development, and pathology of the many variations of anxiety disorder. They review in particular separation anxiety disorder, obsessive-compulsive disorder, specific phobias, panic disorder with and without agoraphobia, and generalized anxiety disorder, indicating what is unique to each of them but emphasizing as well the importance of recognizing what may in fact be common to them all. These authors provide a very thorough life span developmental understanding, again representing well divergent perspectives within an integrative conceptualization.

Regrettably, the prior edition of this text did not include a chapter on sex and gender identity disorders. This gap in coverage is filled very well by the next chapter provided by Peggy J. Kleinplatz and Charles Moser, covering sexual dysfunctions, paraphilias, and gender identity issues. They consider psychological, interpersonal, psychosocial, and medical contributions to the etiology and pathology of sexual dysfunctions. They cover ongoing controversies surrounding the paraphilias, such as the need to distinguish between normophilic and paraphilic interactions. They consider a number of controversies surrounding DSM-5, such as the emergence of a transgender community's reaction to diagnostic labeling.

The next two chapters separated themselves somewhat from DSM-IV-TR, but in the end appear to have been quite prescient. Etzel Cardena, Lisa D. Butler, Sophie Reijman, and David Spiegel again call for a section of the manual devoted to disorders of extreme stress that would include conditions currently classified in different sections of the diagnostic manual. This proposal received formal approval for consideration in DSM-5. In the end, it might not be approved at all (and is unlikely to be approved in a manner entirely consistent with the suggestions of Cardena and colleagues), but it is evident that these authors are on the cutting edge of this area of psychopathology. There is perhaps much to appreciate and understand through the integrative conceptualization of the dissociative, posttraumatic stress, acute stress, and conversion disorders within one common section of the diagnostic manual.

In an analogous albeit different theoretical perspective, Kenneth J. Sher, Rachel Winograd, and Angela Haeny provide an integrative review of disorders of impulse dyscontrol. They covered within the prior version of this chapter pathological gambling as well as alcohol and drug usage. Their updated version of this chapter is again quite timely, as a formal proposal for DSM-5 is to shift substance use disorders and pathological gambling into a new section of the diagnostic manual for behavior addictions. Sher and colleagues provide again the empirical and conceptual support for this major revision to the diagnosis and conceptualization of substance use disorders and pathological gambling.

The final chapter by Philip D. Harvey and Christopher R. Bowie covers a variety of disorders included within a common spectrum of schizophrenia-related dysfunction. For example, one of the major proposals for DSM-5 is to shift schizotypal personality disorder out of the personality disorders and into a new section of schizophrenia-spectrum disorders that Harvey and Bowie eloquently conceptualize. They also indicate how pharmacological interventions have met with limited success, whereas cognitive remediation interventions have made considerable strides in the past decade. Like many other domains of research and treatment, advances in mapping the human genome and understanding the complexities of inheritance of behavioral traits have improved the understanding of schizophrenia. The future of research and treatment in schizophrenia spectrum conditions will likely include advances in understanding the neuroscience of social behavior and social cognition, as well as developing combination therapies employing psychosocial/behavioral interventions and pharmacotherapy.

Following the description of the range of psychopathology in Part I, the volume then moves into an account of the treatment of those disorders in Part II, which begins with three chapters that describe the major orientations toward psychotherapy—psychodynamic, cognitive-behavioral, and humanistic—and adds an account of an exciting new development that transcends single schools: psychotherapy integration.

The first chapter in Part II covers the oldest of the single schools of psychotherapy, psychodynamic psychotherapy, and it is described thoroughly and well by Larry Josephs and Joel Weinberger. Psychodynamic psychotherapy is not limited to the work of Freud; and although the contributions of the founder are described thoroughly, so are more recent developments in British object relations and American interpersonal theories, the self psychology movement, and contemporary intersubjective and relational theories. The research that supports much of this work also is described.

The primary single school alternative to psychodynamic psychotherapy is behavioral and cognitive-behavioral psychotherapy, and this is presented thoroughly and well by W. Edward Craighead, Linda Craighead, Lorie Ritschel, and Alexandra Zagoloff. This, too, is not a simple and unitary approach, but combines both behavior therapy and cognitive-behavioral psychotherapy, each of which has many variations. The clinical approach is integrated in the presentation with extensive research evidence, and the description of specific treatments for specific syndromes can be read in conjunction with many of the chapters in Part I that describe these syndromes in more detail. Along with psychodynamic psychotherapy and behavioral and cognitive-behavioral psychotherapy, there always has been a third force, the humanistic-experiential school. This is covered by Leslie Greenberg, Robert Elliott, Germain Lietaer, and Jeanne Watson and it also incorporates many individual approaches within the generic orientation, such as person-centered, Gestalt, existential, and experiential therapy. They all share a commitment to a phenomenological approach, a belief in the uniquely human capacity for reflective consciousness and growth, and a positive view of human functioning. Here, as in all the psychotherapy chapters, research evidence also is covered.

The fourth chapter that deals with individual psychotherapy does not recognize the boundaries established by schools, which themselves, as we have seen, are more heterogeneous than is commonly believed. Rather, psychotherapy integration seeks to take from each that which is most useful, and these attempts are described by Jerry Gold and George Stricker. Just as the single schools are more complex than initially appears to be the case, psychotherapy integration is made up of many different attempts at rapprochement, drawing freely from all other theoretical and technical approaches and from research evidence. It is interesting to note that many of the leading practitioners of individual schools, including most of the authors of the chapters presenting those schools, are involved in attempts at a higher order integration of their work, which should work for the benefit of the patients that are served.

Aside from the individual approaches to psychotherapy, two other modalities are quite prominent. Patients are seen not only as individuals but also in groups or along with other members of their family. Group psychotherapy is described by William Piper and Carlos Sierra. The goals of group therapy vary from overall personality reorganization to symptom-focused work and deal with patients in outpatient and inpatient settings. There also is a gamut of theoretical approaches that parallel the approaches that have been described in the chapters covering individual orientations to psychotherapy.

Family therapy is covered by Jay Lebow and Catherine Stroud. Although an understanding of family systems theory is necessary for this work, the variations in application are every bit as great as in individual and group psychotherapy, if not greater. Many approaches to family therapy are becoming integrative, consistent with the reports of an earlier chapter. Alongside the typical approaches to psychotherapy, specific attention is given to culturally competent family therapy and gender-sensitive approaches to family therapy.

Two very popular approaches that represent applications of psychotherapy in specific situations or formats are crisis intervention therapy and brief psychotherapy. Crisis intervention is the focus of the chapter by Lisa M. Brown, Kathryn Frahm, and Bruce Bongar. Crisis intervention involves the provision of emergency mental health care to individuals and groups. Crises can refer to unusual and devastating events or to milestones in human life. Examples are given concerning care to suicidal patients, survivors of disaster, and patients and families struggling with debilitating illness. The immediate response to these crises can be of great help to the victim and also can provide the opportunity for much human growth. Cultural considerations, current research, and issues in working with mental health teams are reviewed, along with the many theoretical approaches that are taken to resolving crises.

The brief psychotherapies are presented by Stanley B. Messer, William C. Sanderson, and Alan S. Gurman. Brief versions of each of the major orientations, including psychotherapy integration, are described, and a brief approach to marital and family psychotherapy is also covered. It may be a reflection of the current health-care scene that there is more attention given to working in a more abbreviated fashion, but this is not necessarily second best, and the chapter makes clear how much good work can be done in a shorter time frame than is customarily considered.

Up to this point every chapter has focused on the adult population. However, in a life span framework, the other ends of the chronological spectrum also must be considered. Child psychotherapy is described by Richard J. Morris, Kristin Thompson, and Yvonne P. Morris. Although the title is narrow, the conception includes adolescents as well as children, and the approaches cover the usual spectrum ranging from psychodynamic to cognitive-behavioral to humanistic approaches. Given the formative importance of early experience, the treatment of younger people is an important contribution to the mental health of the population, and this chapter covers the various indications and approaches.

At the other end of the age spectrum, the approaches to treating the older patient are presented by Bob G. Knight and Jennifer Kellough. They adopt an integrative model, drawing on the usual approaches to individual treatment and adopting methods, where necessary, to the needs of the older adult. The chapter uses Knight's Contextual Adult Life Span Theory for Adapting Psychotherapy to guide the consideration of ways in which the treatment of older adults differs from treatment of younger adults.

Finally, Part II concludes with a chapter on Evidence-based practice by Barry Duncan and Robert J. Reese. This is an area of enormous current interest, and the authors cover a controversial area by giving attention to all of the requirements involved for true evidence-based practice to take place. A critical distinction between evidence-based practice and empirically supported techniques is made.

In each of the chapters in Part II, concerned as they all are with psychotherapy, the picture arises of a field marked by great heterogeneity. The value of integration is presented, either in a specific chapter devoted to psychotherapy integration or as incorporated in many other chapters that deal with specific populations or modalities. Each chapter presents evidence for the approach being presented, and the picture of an evolving and developing field, marked by great promise and great accomplishment, is clear.

Clinical psychology is a science and a practice, and both elements have been presented consistently throughout the first two parts. It also is a profession, and issues that concern the profession are the topic of Part III. It is not sufficient for an individual to declare himself to be a clinical psychologist; rather, much training is required, and credentials are necessary so that members of the public who wish to use the service of professional psychologists can be well-informed and well-served. Concerns about the education, training, licensing, and credentialing of clinical psychologists are presented by Judy E. Hall and Elizabeth M. Altmaier. They cover these issues as manifested in the United States, Canada, and also in Latin America and the European Union. They also address the recent emphasis on mobility and the comparability of training and credentials in a context of accountability.

A profession must be self-regulating and serve the interests of the public if it is to be established and accepted. One necessary component of self-regulation is ethical practice, and issues about ethics that relate to clinical psychology are described by Jeffrey Barnett and Stephen Behnke. The APA ethics code is generic and applies to all psychologists, but this chapter focuses on those issues that are of most concern to the clinical psychologist. These include major ethical practice issues and frequent problems experienced by practitioners. Familiarity with these issues and their successful resolution are necessary for the sound practitioner, and this presentation should help to focus the potential problem areas and the models of understanding and resolving them.

Clinical psychology is practiced in a social context, and the changing context has had a marked effect on the nature of the practice. The health-care marketplace in the United States is described by David J. Drum and Andrew Sekel. Their survey is both historical and conceptual, and it traces the evolution of health care in the United States from its early stage of self-regulation and independence to the current stage of input from multiple stakeholders in health-care delivery. The implication this has for the future is not clear, of course, but some very educated guesses are offered, as well as the identification of key areas of concern.

Finally, we turn our attention to the future. Patrick H. DeLeon, Morgan Sammons, Sandra Wilkniss, Kristofer Hagglund, Stephen Ragusea, and Anthony Ragusea explore areas of expanding roles for psychologists in future years. They discuss the impact of the new health-care legislation and other cutting-edge areas such as primary care practice, telehealth, public health, and prescriptive authority and policy opportunities. As our society evolves, the field of clinical psychology also must evolve, and these authors lay out many possibilities for growth and development.

Clinical psychology is an expanding science and profession, and its capacity to continue to be relevant depends on its ability to adapt to changing social conditions, needs, and opportunities. We began with an account of historical factors, attempted to provide a context for the current state of the field, presented chapters that described these developments in detail, and concluded with a look toward the future. Clinical psychology has made major contributions to the discipline of psychology and to the welfare of society, and it shows every indication of continuing to grow and evolve with the world about it, and, by doing so, to retain its position at the forefront of scientific and professional developments. We hope that we have been successful in outlining these possibilities and that we will be witness to continued growth and development.

George Stricker

Thomas A. Widiger

References

American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed., Text Revision). Washington, DC: Author.

Benjamin, L. T. (1996). Lightner Witmer's legacy to American psychology. American Psychologist, 51, 235–236.

Hilgard, E. R. (1987). Psychology in America: A historical survey. New York, NY: Harcourt Brace Jovanovich.

Murray, H. A. (1956). Morton Prince. Journal of Abnormal Psychology, 52, 291–295.

Witmer, L. (1907). Clinical psychology. The Psychological Clinic, 1, 1–9.

Contributors

Elizabeth M. Altmaier, PhD

Department of Psychological and Quantitative Foundations

University of Iowa

Iowa City, IA

David H. Barlow, PhD, ABPP

Department of Psychology

Boston University

Boston, MA

Jeffrey E. Barnett, PsyD, ABPP

Department of Psychology

Loyola University Maryland

Baltimore, MD

Stephen H. Behnke, JD, PhD

American Psychological Association Ethics Office

750 First Street, NE

Washington, DC 20002

Bruce Bongar, PhD, ABPP

Palo Alto University

Palo Alto, CA

and

Department of Psychiatry and Behavioral Sciences

Stanford University School of Medicine

Stanford, CA

Christopher R. Bowie, PhD

Departments of Psychology and Psychiatry

Queen's University

Kingston, Ontario, Canada

Lisa M. Brown, PhD

School of Aging Studies

College of Behavioral and Community Sciences

University of South Florida

Tampa, FL

Kenneth R. Bruce, PhD

Eating Disorders Program

Douglas Hospital

Department of Psychiatry

McGill University

Montreal, Quebec, Canada

Lisa D. Butler, PhD

School of Social Work

State University of New York

Buffalo, NY

Etzel Cardena, PhD

Department of Psychology

Lund University

Lund, Sweden

Ryan J. Carpenter, BA

Department of Psychological Science

University of Missouri

Columbia, MO

Linda W. Craighead, PhD

Department of Psychology

Emory University

Atlanta, GA

W. Edward Craighead, PhD

Department of Psychiatry and Behavioral Sciences

Department of Psychology

Emory University

Atlanta, GA

Cristina Crego, BA

Department of Psychology

University of Kentucky

Lexington, KY

Patrick H. DeLeon, PhD

Former APA President

David J Drum, PhD, ABPP

Department of Educational Psychology

University of Texas

Austin, TX 78712

Barry Duncan, PsyD

The Heart and Soul of Change Project

Jensen Beach, FL

Robert Elliott, PhD

School of Psychological Sciences and Health

University of Strathclyde

Glasgow, Scotland

UK

Kathryn A. Frahm, PhD

School of Aging Studies

University of South Florida

Tampa, FL

Kaitlin P. Gallo, MA

Department of Psychology

Boston University

Boston, MA

Jerry Gold, PhD, ABPP

Derner Institute of Advanced Psychological Studies

Adelphi University

Garden City, NY

Leslie S. Greenberg PhD

Department of Psychology

York University

4700 Keele St.

Toronto, ON, Canada

Alan S. Gurman, PhD

The Family Institute at Northwestern University

Evanston, IL

and

Clinical Psychology Doctoral Program

University of Wisconsin

Madison, WI

Angela Haeny, MA

Department of Psychological Science

University of Missouri

Columbia, MO

Kristofer J. Hagglund, PhD

School of Health Professions and MPH Program

University of Missouri

Columbia, MO

Judy E. Hall, PhD

Executive Officer

National Register of Health Service Providers in Psychology

Washington, DC

Constance Hammen, PhD

Department of Psychology

University of California

Los Angeles, CA

Philip D. Harvey, PhD

Department of Psychiatry and Behavioral Sciences

University of Miami Miller School of Medicine

Miami, FL

Mimi Israel, MD

Eating Disorders Program

Douglas Hospital

Department of Psychiatry

McGill University

Montreal, Quebec, Canada

Lawrence Josephs, PhD

Derner Institute of Advanced Psychological Studies

Adelphi University

Garden City, NY

Danielle Keenan-Miller, PhD

Department of Psychology

University of Southern California

Los Angeles, CA

Jennifer L. Kellough, MA

Department of Psychology

University of Southern California

Los Angeles, CA

Peggy J. Kleinplatz, PhD

Department of Psychiatry

University of Ottawa

Ottawa, Ontario, Canada

Bob G. Knight, PhD

Davis School of Gerontology and Department of Psychology

University of Southern California

Los Angeles, CA

Jay L. Lebow, PhD, ABPP

Family Institute at Northwestern University

Evanston IL

Arlene Istar Lev, LCSW-R, CASAC

School of Social Welfare

University at Albany

Albany, NY

Germain Lietaer, PhD

Department of Clinical Psychology

Catholic University Leuven

Leuven, Belgium

Eric J. Mash, PhD

Department of Psychology

University of Calgary

Calgary, Alberta, Canada

Stanley B. Messer, PhD

Graduate School of Applied and Professional Psychology

Rutgers University

Piscataway, NJ

Richard J. Morris, PhD

School Psychology Program

University of Arizona

College of Education

Tucson, AZ

Yvonne P. Morris, PhD

Private Practice

Tucson, AZ

Charles Moser, MD, PhD

Department of Sexual Medicine

Institute for Advanced Study of Human Sexuality

San Francisco, CA

Donna B. Pincus, PhD

Department of Psychology

Boston University

Boston, MA

William E. Piper, PhD

Department of Psychiatry

The University of British Columbia

Vancouver, BC

Anthony S. Ragusea, PsyD

Private Practice

Key West, FL

Stephen A. Ragusea, PsyD

Private Practice

Key West, FL

Robert J. Reese, PhD

Department of Educational, School, & Counseling Psychology

University of Kentucky

Lexington, KY

Sophie Reijman, BSc

Child and Family Studies

Leiden University

Leiden, The Netherlands

Lorie A. Ritschel, PhD

Department of Psychiatry and Behavioral Sciences

Emory University School of Medicine

Atlanta, GA

Morgan T. Sammons, PhD, ABPP

California School of Professional Psychology

San Francisco, CA

William C. Sanderson, PhD

Department of Psychology

Hofstra University

Hempstead, NY 11549

Andrew Sekel, PhD

Chief Executive Officer

OptumHealth Behavioral Solutions

San Francisco, CA

Kenneth J. Sher, PhD

Department of Psychological Science

University of Missouri

Columbia, MO

Carlos A. Sierra Hernandez, BA

Department of Psychiatry

The University of British Columbia

Vancouver, BC

David Spiegel, MD

Department of Psychiatry and Behavioral Sciences

Stanford University

Stanford, CA

Howard Steiger, PhD

Eating Disorders Program

Douglas Hospital

Department of Psychiatry

McGill University

Montreal, Quebec, Canada

George Stricker, PhD, ABPP

Dept. of Clinical Psychology

American School of Professional Psychology at Argosy University, Washington DC

Arlington, VA 22209

Catherine Stroud, PhD

Department of Psychology

Williams College

Williamstown, MA 01267

Kristin C. Thompson, PhD

School Psychology Program

University of Arizona

College of Education

Tucson, AZ 85721

Johanna Thompson-Hollands, MA

Department of Psychology

Boston University

Boston, Massachusetts

Timothy J. Trull, PhD

Department of Psychological Science

University of Missouri,

Columbia, Missouri

Jeanne Watson, PhD

Dept. of Adult Education and Counselling Psychology

University of Toronto, Toronto

Canada, M5S 1V6

Joel Weinberger, PhD

Derner Institute of Advanced Psychological Studies

Adelphi University, Garden City, NY

Garden City, NY 11530

Thomas A Widiger, PhD

Department of Psychology

University of Kentucky

Lexington, Kentucky

Sandra M. Wilkniss, PhD

APA/AAAS Congressional Fellow

Arlington, VA 22205

Rachel Winograd, MA

Department of Psychological Science

University of Missouri,

Columbia, Missouri

David A. Wolfe, PhD

Center for Addiction and Mental Health

University of Toronto

Toronto, Ontario, Canada

Alexandra Zagoloff, PhD

Department of Psychiatry and Behavioral Sciences

Emory University

Atlanta, GA 30306

Part I

Psychopathology

Chapter 1

Diagnosis and Classification

Thomas A. Widiger and Cristina Crego

Historical Background

Continuing Issues for ICD-11 and DSM-5

Conclusions

References

Human beings engage in a wide array of behaviors, including eating, sleeping, talking, feeling, thinking, playing, buying, and having sex. All of these forms of behavior include a maladaptive variant that is diagnosed as a mental disorder by the American Psychiatric Association. Dysfunctional, aberrant, and maladaptive feeling, thinking, behaving, and relating to others are of substantial concern to many different professions, the members of which hold an equally diverse array of opinions regarding etiology, pathology, and treatment. It is imperative that these persons be able to communicate meaningfully with one another. The primary purpose of an official diagnostic nomenclature is to provide this common language of communication (Kendell, 1975; Sartorius et al., 1993).

An official diagnostic nomenclature, however, can be an exceedingly powerful document, impacting many important social, forensic, clinical, and other professional decisions (Schwartz & Wiggins, 2002). Persons think in terms of their language and the predominant languages of psychopathology are the fourth edition of the American Psychiatric Association's (1994, 2000) Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR) and the 10th edition of the World Health Organization's (WHO) International Classification of Diseases (ICD-10; WHO, 1992). As such, these nomenclatures have a substantial impact on how clinicians, social agencies, the government, and the general public conceptualize aberrant, problematic, and maladaptive behavior.

Interpreting DSM-IV-TR or ICD-10 as conclusively validated nomenclatures, however, exaggerates the extent of their scientific support (Frances, Pincus, Widiger, Davis, & First, 1990; Frances & Widiger, in press). There is little within DSM-IV-TR or ICD-10 that is not subject to significant dispute. Mental disorders are to a substantial extent constructions of clinicians and researchers rather than proven, evident diseases or illnesses (Maddux, Gosselin, & Winstead, 2008). On the other hand, the diagnoses contained within DSM-IV-TR and ICD-10 are not necessarily lacking in credible or compelling empirical support. DSM-IV-TR and ICD-10 contain many flaws, but they are also well-reasoned, scientifically researched, and, for the most part, well-documented nomenclatures that describe what is currently understood by most scientists, theorists, researchers, and clinicians to be the predominant forms of psychopathology (Widiger, in press). This chapter overviews the DSM-IV-TR diagnostic nomenclature, beginning with historical background, followed by a discussion of the major issues facing the forthcoming DSM-5 and future revisions.

Historical Background

The impetus for the development of an official diagnostic nomenclature was the chaos and confusion generated by its absence (Widiger, 2001). For a long time confusion reigned. Every self-respecting alienist [the 19th-century term for a psychiatrist], and certainly every professor, had his own classification (Kendell, 1975, p. 87). For the young, aspiring professor, the production of a new system for classifying psychopathology was a standard rite of passage in the 19th century.

To produce a well-ordered classification almost seems to have become the unspoken ambition of every psychiatrist of industry and promise, as it is the ambition of a good tenor to strike a high C. This classificatory ambition was so conspicuous that the composer Berlioz was prompted to remark that after their studies have been completed a rhetorician writes a tragedy and a psychiatrist a classification. (Zilboorg, 1941, p. 450)

In 1908, the American Bureau of the Census asked the American Medico-Psychological Association (which subsequently altered its title in 1921 to the American Psychiatric Association) to develop a standard nosology to facilitate the obtainment of national statistics:

The present condition with respect to the classification of mental diseases is chaotic. Some states use no well-defined classification. In others the classifications used are similar in many respects but differ enough to prevent accurate comparisons. Some states have adopted a uniform system, while others leave the matter entirely to the individual hospitals. This condition of affairs discredits the science. (Salmon, Copp, May, Abbot, & Cotton, 1917, pp. 255–256)

The American Medico-Psychological Association, in collaboration with the National Committee for Mental Hygiene, issued a nosology in 1918, titled Statistical Manual for the Use of Institutions for the Insane (Menninger, 1963). This nomenclature, however, failed to obtain wide acceptance. It included only 22 diagnoses and these were confined largely to psychoses with a presumably neurobiological pathology. Therefore, in the late twenties, each large teaching center employed a system of its own origination, no one of which met more than the immediate needs of the local institution (American Psychiatric Association, 1952, p. v). There was no common, unified system of diagnosis. Patients being treated at one clinic were given different diagnoses than patients treated at another clinic. Consistent, accumulative research was difficult to produce as each researcher studied his or her own constructions, rarely building upon a common scientific base. A conference was held at the New York Academy of Medicine in 1928 to develop a more authoritative and uniformly accepted manual. The resulting nomenclature was modeled after the Statistical Manual but it was distributed to hospitals within the American Medical Association's Standard Classified Nomenclature of Disease. Many hospitals used this system but it eventually proved to be inadequate when the attention of the profession expanded well beyond psychotic disorders during World War II. ICD-6 and DSM-I

The Navy, Army, and Veterans Administration developed their own, largely independent nomenclatures during World War II due in large part to the inadequacies of the Standard Classified. Military psychiatrists, induction station psychiatrists, and Veterans Administration psychiatrists, found themselves operating within the limits of a nomenclature specifically not designed for 90% of the cases handled (American Psychiatric Association, 1952, p. vi). The World Health Organization (WHO) accepted the authority in 1948 to produce the sixth edition of the International Statistical Classification of Diseases, Injuries, and Causes of Death (ICD). ICD-6 was the first edition to include a section devoted to mental disorders (Kendell, 1975), perhaps in recognition of the many psychological casualties of World War II, as well as the increasing impact and contribution of mental health professions within the broader society. The United States Public Health Service commissioned a committee, chaired by the psychiatrist George Raines (notably though with representations from a variety of other professions and public health agencies) to develop a variant of the mental disorders section of ICD-6 for use within the United States. The United States, as a member of the WHO, was obliged to use ICD-6, but adjustments could be made to maximize the acceptance and utility of ICD-6 within the United States. The resulting nomenclature resembled closely the Veterans Administration system developed by Brigadier General William Menninger (brother to Karl Menninger, 1963). Responsibility for publishing and distributing this nosology was given to the American Psychiatric Association (1952) under the title Diagnostic and Statistical Manual: Mental Disorders (hereafter referred to as DSM-I).

DSM-I was generally successful in obtaining acceptance, due in large part to its expanded coverage, particularly the inclusion of somatoform disorders, stress reactions, and personality disorders. DSM-I also included narrative descriptions of each disorder to facilitate understanding and more consistent applications. Nevertheless, fundamental criticisms regarding the reliability and validity of psychiatric diagnosis were also being raised (e.g., Scheff, 1966; Szasz, 1960; Zigler & Phillips, 1961). For example, a widely cited reliability study by Ward, Beck, Mendelson, Mock, and Erbaugh (1962) concluded that most of the poor agreement among psychiatrists' diagnoses was due largely to inadequacies of DSM-I, and more specifically, its failure to provide specific, explicit guidelines as to the diagnostic criteria for each respective disorder, allowing clinicians to vary widely in how they applied the diagnostic system.

ICD-6 was even less successful. The mental disorders section [of ICD-6] failed to gain [international] acceptance and eleven years later was found to be in official use only in Finland, New Zealand, Peru, Thailand, and the United Kingdom (Kendell, 1975, p. 91). The WHO therefore commissioned a review by the English psychiatrist, Erwin Stengel. Stengel (1959) reiterated the importance of establishing an official nomenclature.

A…serious obstacle to progress in psychiatry is difficulty of communication. Everybody who has followed the literature and listened to discussions concerning mental illness soon discovers that psychiatrists, even those apparently sharing the same basic orientation, often do not speak the same language. They either use different terms for the same concepts, or the same term for different concepts, usually without being aware of it. It is sometimes argued that this is inevitable in the present state of psychiatric knowledge, but it is doubtful whether this is a valid excuse. (Stengel, 1959, p. 601)

Stengel (1959) attributed the failure of clinicians to accept the mental disorders section of ICD-6 to the presence of theoretical biases, cynicism regarding any psychiatric diagnoses (some theoretical perspectives opposed the use of any diagnostic terms), and the presence of abstract, highly inferential diagnostic criteria that hindered consistent, uniform applications by different clinicians.

ICD-8 and DSM-II

ICD-6 had been revised to ICD-7 in 1955 but there were no revisions to the mental disorders section. Work began on ICD-8 soon after Stengel's 1959 report. The final edition was approved by the WHO in 1966 and became effective in 1968. A companion glossary, in the spirit of Stengel's (1959) recommendations, was to be published conjointly, but work did not begin on the glossary until 1967 and it was not completed until 1972. This delay greatly reduced [its] usefulness, and also [its] authority (Kendell, 1975, p. 95). In 1965, the American Psychiatric Association appointed a committee, chaired by Ernest M. Gruenberg, to revise DSM-I to be compatible with ICD-8 and yet also be suitable for use within the United States. The final version was approved in 1967, with publication in 1968.

The diagnosis of mental disorders, however, was continuing to receive substantial criticism (e.g., Rosenhan, 1973). A fundamental problem continued to be the absence of empirical support for the reliability, let alone the validity, of its diagnoses (e.g., Blashfield & Draguns, 1976). Researchers, therefore, took to heart the recommendations of Stengel (1959) to develop more specific and explicit criterion sets (Blashfield, 1984). The most influential of these efforts was produced by a group of neurobiologically oriented psychiatrists at Washington University in St. Louis. Their criterion sets generated so much interest that they were published separately in what has become one of the most widely cited papers in psychiatry (i.e., Feighner et al., 1972).

The Feighner et al. (1972) criterion sets were confined to just the 15 disorders of primary interest to the Washington University researchers. Their approach to diagnosis was greatly expanded by Robert Spitzer (a technical consultant for DSM-II; American Psychiatric Association, 1968) into a manual that covered a much wider variety of diagnosis, titled the Research Diagnostic Criteria (RDC; Spitzer, Endicott, & Robins, 1978). The RDC was adopted by many research programs around the world, and contributed to the obtainment of more consistent and replicable research findings. This subsequent research using specific and explicit criterion sets assessed with structured interviews has since indicated that mental disorders can be diagnosed reliably and do provide valid information regarding etiology, pathology, course, and treatment (Kendler, Munoz, & Murphy, 2010).

ICD-9 and DSM-III

By the time Feighner et al. (1972) was published, work was nearing completion on ICD-9. The authors of ICD-9 had decided to include a glossary, but it was apparent that it would not include the more specific and explicit criterion sets developed and used in research (Kendell, 1975). In 1974, the American Psychiatric Association appointed a Task Force, chaired by Robert Spitzer, to revise DSM-II in a manner that would be compatible with ICD-9 but would also incorporate many of the advances in diagnosis currently being developed. DSM-III was published in 1980 and was remarkably innovative, including (a) a multiaxial diagnostic system (most mental disorders were diagnosed on Axis I, personality and specific developmental disorders were diagnosed on Axis II, medical disorders on Axis III, psychosocial stressors on Axis IV, and level of functioning on Axis V), (b) specific and explicit criterion sets for all but one of the disorders (i.e., schizoaffective), (c) a substantially expanded text discussion of each disorder to facilitate diagnosis (e.g., age of onset, sex ratio, course, complications, and familial pattern), and (d) removal of terms (e.g., neurosis) that appeared to favor a particular theoretical model for the disorder's etiology or pathology (Spitzer, Williams, & Skodol, 1980).

DSM-III-R

Many of the criterion sets developed for DSM-III lacked much prior history or field testing. Most were constructed by work group members with little guidance as to how they would in fact work in general clinical practice or even research settings. As a result, a number of obvious errors occurred (e.g., panic disorder in DSM-III could not be diagnosed in the presence of major depression). Criteria were not entirely clear, were inconsistent across categories, or were even contradictory (American Psychiatric Association, 1987, p. xvii). The American Psychiatric Association therefore authorized the development of a revision to DSM-III to make corrections and refinements. Fundamental revisions were to be tabled until work began on ICD-10. However, it might have been unrealistic to expect the authors of DSM-III-R to confine their efforts to refinement and clarification, given the impact, success, and importance of DSM-III.

The impact of DSM-III has been remarkable. Soon after its publication, it became widely accepted in the United States as the common language of mental health clinicians and researchers for communicating about the disorders for which they have professional responsibility. Recent major textbooks of psychiatry and other textbooks that discuss psychopathology have either made extensive reference to DSM-III or largely adopted its terminology and concepts. (American Psychiatric Association, 1987, p. xviii)

Prior to DSM-III there were few psychiatrists or psychologists particularly interested in diagnosis and classification. Subsequent to DSM-III, psychiatric diagnosis became a major focus of scientific research. It was not difficult to find persons who wanted to be involved in the development of DSM-III-R, and everyone wanted to have a significant impact. Ironically, there were considerably more persons involved in DSM-III-R than in DSM-III, yet its mission was purportedly far more conservative and limited in scope. Not surprisingly, in the end, there were many proposals for major revisions and even new diagnoses. In fact, four of the diagnoses approved for inclusion by the authors of DSM-III-R (i.e., self-defeating personality disorder, sadistic personality disorder, late luteal phase dysphoric disorder [the name for which was subsequently changed to premenstrual dysphoric disorder], and paraphiliac rapism) generated so much controversy that a special ad-hoc committee was appointed by the Board of Trustees of the American Psychiatric Association to reconsider their inclusion. A concern common to them all was that their inclusion might result in harm to women. For example, self-defeating personality disorder might have been used to blame female victims for having been abused, whereas sadistic personality disorder could be used to help mitigate the criminal responsibility of the abusing spouse. Paraphiliac rapism could likewise be used to mitigate criminal responsibility for rape. Another concern was the lack of sufficient empirical support to address or offset these concerns. A compromise was eventually reached in which the two personality disorders and late luteal phase dysphoric disorder were included in an appendix (Endicott, 2000; Widiger, 1995); paraphiliac rapism was deleted entirely.

ICD-10 and DSM-IV

Work on DSM-III-R was supposed to have been completed in 1985, but given the ever-expanding breadth of its expansions and revisions, by the time work was completed on DSM-III-R, work had already begun on ICD-10. The decision of the authors of DSM-III to develop an alternative to ICD-9 (i.e., include specific and explicit criterion sets) was instrumental in developing a highly innovative manual (Kendell, 1991; Spitzer et al., 1980). However, its innovations were also at the cost of decreasing compatibility with the ICD-9 nomenclature that was used throughout the rest of the world, which is problematic to the stated purpose of providing a common language of communication. In 1988, the American Psychiatric Association appointed a DSM-IV Task Force, chaired by Allen Frances (Frances, Widiger, & Pincus, 1989). Mandates for DSM-IV included better coordination with ICD-10 and improved documentation of empirical support.

The DSM-IV committee aspired to use a more conservative threshold for the inclusion of new diagnoses and to have decisions that were guided more explicitly by the scientific literature (Frances & Widiger, in press). Proposals for additions, deletions, or revisions were guided by literature reviews that were required to use a specific meta-analytic format that maximized the potential for informative critical review, containing (for example) a method section that explicitly documented the criteria for including and excluding studies and the process by which the literature had been reviewed (Frances et al., 1989). The purpose of this structure was to make it easier to discover whether the author was confining his or her review only to studies that were consistent with a particular proposal, and failing to acknowledge opposing perspectives. These reviews were published within a three-volume DSM-IV Sourcebook (e.g., Widiger et al., 1994). Testable questions that could be addressed with existing data sets were also explored in additional studies, which emphasized the aggregation of multiple data sets from independent researchers, and 12 field trials were conducted to provide reliability and validity data on proposed revisions. The primary purposes of the field trials were to address fundamental questions or concerns with regard to a particular proposal, as well as to compare and contrast alternative proposals. The results of the field trials were published in the fourth volume of the DSM-IV Sourcebook (Widiger et al., 1998). Perhaps most importantly, critical reviews of these projects were obtained by sending initial drafts to advisors or consultants to a respective work group, by presenting drafts at relevant conferences, and by submitting drafts to peer-reviewed journals (Widiger, Frances, Pincus, Davis, & First, 1991; Widiger & Trull, 1993).

DSM-IV-TR

One of the innovations of DSM-III was the inclusion of a relatively detailed text discussion of each disorder, including information on age of onset, gender, course, and familial pattern (Spitzer et al., 1980). This text was expanded in DSM-IV to include cultural and ethnic group variation, variation across age, and laboratory and physical exam findings (Frances et al., 1995). Largely excluded from the text was information concerning etiology, pathology, and treatment as this material was considered to be too theoretically specific and more suitable for academic texts. Nevertheless, it had also become apparent that DSM-IV was in fact being used as a textbook, and the material on age, course, prevalence, and family history was quickly becoming outdated as new information was being gathered.

Therefore, in 1997, the American Psychiatric Association appointed a DSM-IV Text Revision Work Group, chaired by Michael First (Editor of the Text and Criterion Sets for DSM-IV) and Harold Pincus (Vice Chair for DSM-IV) to update the text material. No substantive changes in the criterion sets were to be considered, nor were any new additions, subtypes, deletions, or other changes in the status of any diagnoses to be implemented. In addition, each of the proposed revisions to the text had to be supported by a systematic literature review that was critiqued by a considerable number of advisors. The DSM-IV Text Revision (DSM-IV-TR) was published in 2000 (American Psychiatric Association, 2000).

The outcome, however, was not entirely consistent with the original intentions. Revisions were in fact made to the criterion sets for tic disorders and for the paraphilias that involved a nonconsenting victim (First & Pincus, 2002), the latter due to concerns of misapplication within forensic settings (First & Halon, 2008; Frances, 2010a), albeit no acknowledgment of these revisions was provided within the manual. In addition, no documentation of the scientific support for the text revisions was provided, due to the inconsistency in the quality of the effort. Rather than have inconsistent and/or inadequate documentation, it was decided to have none at all.

Continuing Issues for ICD-11 and DSM-5

Work is now well underway for DSM-5, chaired by Drs. David Kupfer and Darrel Regier, with an anticipated publication date of 2013. DSM-5 is likely to include a number of major revisions. The proposals were posted online February 10, 2010, and subsequently revised in January 2011, and June 2011 (see www.dsm5.org). The process and content of DSM-5 have been controversial (Frances, 2009). Five issues for DSM-5 that will be discussed here are (1) the definition of mental disorder, (2) the empirical support for proposed revisions, (3) the impact of culture and values, (4) shifting to a dimensional model, and (5) shifting to a neurobiological model.

Definition of Mental Disorder

One of the more fundamental and central concerns of the diagnostic manual is what constitutes a mental disorder. The boundaries of the diagnostic manual have been increasing with each edition (Kirk, 2005) and there has long been vocal concern that much of this expansion represents an encroachment into normal problems of living (Caplan, 1995; Follette & Houts, 1996; Maddux, Gosselin, & Winstead, 2008). The authors of DSM-5 have been proposing quite a few new diagnoses, such as paraphilic coercive, hypersexual, temper dysregulation of childhood, mixed anxiety-depression, olfactory reference syndrome, hoarding, skin picking, premenstrual dysphoric, pedohebephilic, minor neurocognitive, and binge eating disorder. Frances (2010b), the Chair of DSM-IV, suggests that many of these additions represent a further encroachment into normal problems of living.

Presumably one should be able to infer what is or is not a mental disorder based on a definition of what constitutes a mental disorder, but this has not worked, for a few reasons. First, new proposals for what to include within the DSM tend to come from specialists with a particular interest in a respective syndrome, rather than from any rationale or logical application of any conceptual definition (Frances & Widiger, in press). In addition, there has never been adequate comfort with respect to any particular definition to have it provide authoritative guidance. And, third, the definitions that have been proposed have been so broad and/or vague regarding key constructs that they are unable to provide such guidance.

The definition of mental disorder provided in DSM-IV-TR (American Psychiatric Association, 2000) was the result of an effort by the authors of DSM-III to develop specific and explicit criteria for deciding whether a behavior pattern (homosexuality in particular) should be classified as a mental disorder (Spitzer & Williams, 1982). The intense controversy over homosexuality has largely abated, but the issues raised in this historical debate continue to fester. For example, in order to be diagnosed with pedophilia, DSM-III-R (American Psychiatric Association, 1987) required only that an adult have recurrent intense urges and fantasies involving sexual activity with a prepubescent child over a period of 6 months and have acted on them (or be markedly distressed by them). However, a difficulty with this definition is that every adult who engaged in a sexual activity with a child for longer than 6 months would meet these diagnostic criteria. The authors of DSM-IV were concerned that DSM-III-R was not providing adequate guidance for determining when deviant sexual behavior is the result of a mental disorder. Presumably, some persons can engage in deviant, aberrant, and even heinous activities without being compelled to