Diagnosis and Treatment of Mental Disorders: An Introduction

By Timothy C. Thomason

This book is a practical introductory guide for graduate students and novice psychotherapists in clinical and counseling psychology. It provides guidance on how to diagnose mental disorders using the DSM-5-TR and addresses current issues and controversies in diagnosis. The book also contains detailed guides on how to treat clients with common mental disorders, including depression, anxiety disorders, posttraumatic stress disorder, obsessive-compulsive disorder, insomnia, hoarding disorder, and others. The book emphasizes the importance of evidence-based diagnosis and treatment in the context of a warm and supportive therapeutic relationship.

• Language: English
• Publisher: BookBaby
• Release date: Feb 10, 2023
• ISBN: 9781667876511

Book preview

PREFACE

This book describes many practical aspects of the process of diagnosing and treating the most common mental disorders. It provides useful guidelines for making accurate diagnoses and providing effective treatments. The emphasis is on the techniques that have the most evidence for their safety and effectiveness. There are many other treatments that may be effective but for which there is little or no evidence that they actually help most clients with mental disorders. This book is an introduction to the topic, and further reading and supervised practice will be necessary to prepare students to diagnose and treat clients. Although members of the general public can get ideas about how to think about their problems from this book, it is not intended as a self-help guide, and readers who have concerns are encouraged to seek assistance from a licensed mental health provider. The last two chapters provide exercises and questions readers can use to further their psychological self-understanding. Regarding terminology, in this book the term clinician is used to refer to all those who conduct clinical assessment and psychotherapy, including psychologists, clinical mental health counselors, clinical social workers, and psychiatrists. The term client is used but is interchangeable with patient, and the term psychotherapy is used synonymously with mental health counseling.

PART ONE

Diagnosis of Mental Disorders

CHAPTER 1

FUNDAMENTALS OF DIAGNOSIS

Psychopathology is the study of mental disorders. It involves impairment, deviance from social norms, and distress, but not all examples of impairment, deviance and distress are pathological. To be considered a mental disorder, a person’s condition must produce clinically significant impairment in daily life and/or a significant amount of distress. The line between psychopathology and normality may be hazy, and the diagnosis of mental disorders is somewhat subjective, but it is the responsibility of the clinician to determine whether a client has a mental disorder, and identify it, so that appropriate treatment can be provided. Diagnosis is the process of identifying the disorder being experienced by the client.

Diagnosis and the DSM-5-TR

Clinicians routinely use the Diagnostic and Statistical Manual of Mental Disorders, fifth edition, text revision (DSM-5-TR) to aid in the diagnosis of mental disorders. Traditionally the counseling profession emphasized a wellness model rather than a medical model, and the humanistic, existential, and postmodern theories fit best in a growth and wellness model. However, the ability to diagnose mental disorders is integral to issues relevant to clients, including Medicare parity, fair and equal access to psychological tests, and integrated health care. The American Counseling Association has advocated for the diagnosis of mental disorders to be included in the scope of practice of licensed counselors, and 36 states include diagnosis in the scope of practice for clinical mental health counselors. These providers are expected to comply with the medical model, at least when diagnosing and treating mental disorders.

The DSM-5-TR was published in 2022 and is updated on an ongoing basis at the American Psychiatric Association website (https://www.psychiatry.org). The manual is meant to be a practical and flexible guide for organizing information to aid in the accurate diagnosis and treatment of mental disorders. Although the DSM is sometimes called the bible of diagnosis, it is much more like a dictionary or encyclopedia than a bible. Although it represents the current state of thinking about diagnosis, clinicians are not required to agree with it or, in some cases, even use it. It is an essential educational resource and can serve as a psychopathology textbook for students to help them understand and diagnose mental disorders (American Psychiatric Association, 2013). Almost all mental health professionals in the U.S. use the DSM-5-TR to make clinical diagnoses, and no other diagnostic system has been more influential.

The DSM-5-TR is a work in progress, and changes are made when its writers agree that revisions are justified by new research. Although there are many controversies about diagnosis and the DSM-5-TR, clinical mental health counselors and psychologists are expected to be knowledgeable about it and proficient in its use. The American Counseling Association Code of Ethics (2014) states that Counselors take special care to provide proper diagnosis of mental disorders and CACREP accreditation standards state that counseling students must learn the principles and methods of diagnosis of mental status. Behavioral health care organizations require psychodiagnosis for treatment approval and payment. Health insurance companies typically will not pay for counseling or psychotherapy unless a DSM-5-TR or ICD diagnosis is provided to justify the insurance claim. Providers who dislike the medical model and DSM diagnosis can avoid it by seeing only clients who can pay for their own treatment.

The DSM-5-TR is the most authoritative of our diagnostic systems, but there are other ways of thinking about how people vary in psychological functioning. The International Classification of Diseases (ICD) uses diagnostic codes to track incidence and prevalence rates and many insurance companies use its disorder codes for reimbursement. There are some differences between the DSM-5-TR and the ICD. The ICD is produced by the World Health Organization, includes all diseases and disorders (not just mental disorders), and the disorder codes are available free on the internet. It describes personality disorders differently from the DSM-5-TR, maintains a distinction between substance abuse and substance dependence (which DSM-5 deleted), and includes some mental disorders not in the DSM-5-TR. The ICD is basically a list of disorders with code numbers, and does not include the wealth of information on each disorder contained in the DSM-5-TR. The eleventh edition of the ICD became available in January 2022.

Another alternative nosology to the DSM-5-TR is the Psychodynamic Diagnostic Manual-2 (PDM-2), which takes a psychodynamic approach to diagnosis, as opposed to the atheoretical approach of the DSM-5-TR. It is not likely to become a competitor to the DSM-5-TR, since the majority of clinicians do not have a psychodynamic orientation. Another alternative classification system is the Hierarchical Taxonomy of Psychopathology (HiTOP), which rejects the traditional categories found in the DSM-5-TR and the ICD and takes a dimensional approach instead. It divides psychopathology into six fluid and interrelated spectra dimensions. Another alternative classification is the Research Domain Criteria (RDoC), which is a research initiative by the NIMH based on the hope that biomarkers for mental disorders will be found and can be used to classify disorders. None of the alternative diagnostic systems have been able to displace the DSM-5-TR as the most popular classification system.

Clinicians should understand that diagnostic categories are human creations and are simply the current best estimate by experts regarding the features of a condition. Mental disorders do not exist in pure forms in nature; rather, they are social constructions (useful abstractions, not real entities). Mental disorders are presumed to exist, but the terms used to name and describe them vary by time, place, and culture.

Psychodiagnosis has two main purposes: to define clinical entities so all clinicians understand what a diagnosis means, and to determine treatment (Kilgus, Maxmen, & Ward, 2016). Clinicians need a common language for describing mental disorders, and the DSM-5-TR provides standard criteria for that purpose. For example, any clinician who uses the term post-traumatic stress disorder is presumed to use the term based on the criteria for the disorder described in the DSM-5-TR. The manual also provides an authoritative guide to current thinking about the conditions that are defined as mental disorders. It is used by researchers to guide their work and by insurance companies and other third-party payers to justify reimbursement for treatment.

Instead of a theoretical approach, the DSM-5-TR takes a descriptive approach, listing the typical features and criteria for each disorder. The manual focuses on the individual person as the basic locus of psychopathology, not families or social systems that may be dysfunctional. However, since every person lives in a family or social context, mental disorders reflect that context. Some disorders are likely caused or exacerbated by pernicious social conditions such as poverty and racism. Although clinicians can and should advocate for needed social changes to reduce psychopathology in the general population, most clinical work involves doing therapy with individuals, couples, or families who request treatment. A common criticism of the DSM-5-TR is that it does not sufficiently acknowledge the effect of social factors on psychopathology.

The DSM classifies mental disorders, not the people who have mental disorders. Clients should be cautioned not to take a diagnostic label too seriously. A diagnosis simply identifies a disorder so it can be treated; it does not describe who the client is as a person or predict how the person’s life will go in the future. In this regard, DSM diagnoses are no different than diagnoses of medical illnesses. A person who has an acute illness usually gets treatment for it and returns to normal within a limited amount of time. Of course there are chronic illnesses and chronic mental disorders. But like most medical illnesses, most mental disorders are not life-long conditions and are very treatable. Having any kind of illness or disorder is distressing, but many patients are relieved and encouraged when their condition is diagnosed, because it means it is a known entity that may have an effective treatment. Even so, many people are reluctant to talk about mental disorders publicly or seek therapy due to legitimate concerns about stigma.

Many criticisms have been leveled against the DSM. For example, although it is assumed that diagnosis has a direct relationship to treatment, this is not always the case. There are no evidence-based treatments for some mental disorders, although research is ongoing. Another criticism is that the DSM diagnoses have poor psychometric validity and reliability (which is true). The system is based on a medical model which focuses on disorder and deficits, with little attention to positive wellness, self-actualization, and patient strengths. It is based on an authoritative and hierarchical expert/patient medical model rather than being collaborative. Another criticism is that the DSM’s focus on psychopathology within individuals means it has little to say about interpersonal and social aspects of mental disorders. Also, there is a danger that the use of diagnostic labels can be stigmatizing and difficult to change, even after the client improves and no longer has the disorder.

Another criticism is that there would seem to be a financial incentive to increase the number of disorders, as has happened over time, for the benefit of clinicians. The American Psychiatric Association makes a significant amount of income from publishing the DSM. The fact that most clients use their health insurance to pay for treatment could also lead unethical clinicians to over-diagnose clients’ conditions to make treatment eligible for reimbursement. The DSM-5-TR includes some information on how culture and ethnicity and gender affects diagnosis, but it could include much more. These and other criticisms are addressed in this and many other books (e.g., Frances, 2013b; Greenberg, 2013; Thomason, 2021).

Some clinical mental health counselors do not particularly like the medical model of which the DSM-5-TR is a part. They would prefer that a more humanistic, developmental, counseling-oriented model be used. Counselors often see clients for problems in living rather than mental disorders, and counselors who work in schools, community agencies, and independent practice may be able to see clients without making a formal diagnosis. However, clinical mental health counselors often see clients with mental disorders, and have to be able to use the DSM-5-TR for diagnosis. Counselors can provide career counseling, couple and family counseling, and counseling for many other issues, but the DSM-5 considers these Z-code (previously V-code) conditions, for which treatment is not considered medically necessary by third-party payers. Clients who want treatment of their condition funded by their insurance company must be given a DSM-5-TR (or ICD-11) diagnosis.

Diagnosing mental disorders is a serious endeavor and has weighty potential consequences. The diagnostic manual can be used to determine who is considered well or ill; what treatment may be offered; who pays for the treatment; who gets disability benefits; and who is eligible for mental health, school, and vocational benefits. Clinicians should take their responsibility to make accurate diagnoses seriously. Many good books are available to help clinicians develop a deeper understanding of the many issues involved in diagnosis (e.g., Dailey, Gill, Karl, & Barrio Minton, 2014; Dziegielewski, 2015; Frances, 2013b; Hammond, 2021; Morrison, 2007, 2014).

Categorical vs. Dimensional Approaches

Clinicians who use the DSM-5-TR should understand that it takes a primarily categorical approach to diagnosis, based on the assumption that one either has or does not have a mental disorder. When disorders are separated into categories, the implication is that they are distinctly different in kind. However, the boundaries between many disorder categories are fluid, and specific symptoms may occur in many different disorders, at varying levels of severity. The authors of the DSM-5 acknowledged that a dimensional approach to mental disorders has validity: Scientific evidence now places many, if not most, disorders on a spectrum with closely related disorders that have shared symptoms (APA, 2013, p. 6).

For example, everyone experiences some amount of worry, and worry is not a mental disorder in itself. However, some people have a great deal of chronic worry that impairs their functioning, and if it is severe enough and meets the criteria, that condition might be diagnosed as a general anxiety disorder. Some people have panic attacks during which they have several physical symptoms and think they are dying, and this could be seen as a very severe form of anxiety. Thus, worry and anxiety disorders exist on a dimension or continuum from worry (not a disorder) to mild, moderate, and severe anxiety disorders. The same is probably true for depression and most other psychological symptoms; sadness is not a mental disorder, but depression is.

Although most mental disorders exist on a continuum, the DSM-5-TR retained the categorical structure for the sake of convenience. Dimensional models reflect reality better than categorical models, but are much more difficult and time-consuming for clinicians to use. The DSM-5-TR has clear and concise descriptions of each mental disorder, with explicit diagnostic criteria, but also provides dimensional measures that cross diagnostic boundaries (APA, 2022, p. 841-857). Clinicians can use the diagnostic categories for convenience while understanding that most disorders actually lie somewhere on a continuum.

The Concept of Normality in Mental Health

One common criticism of clinical diagnosis is that it leads to seeing human experience from a negative, pathological point of view, but this is a misperception (Schwitzer & Rubin, 2015). Most human behavior is functional and normal, and the DSM-5-TR only concerns conditions that meet the criteria for a mental disorder. To be considered a disorder the client’s experience must cause distress, impaired functioning, and/or significantly increased risk of harm. Symptoms that are typical given their context are not considered pathological.

The topic of positive mental health has become popular in psychology, although it promised much more than it has delivered (Ehrenreich, 2010; Horowitz, 2017; Singal, 2021). Clinicians work with people who request help because they are suffering from the effects of a mental disorder and/or their functioning is impaired in daily life. As much as we might like to work with people who do not have a disorder to help them achieve optimal mental health or self-actualization, few people request that kind of help from mental health professionals. Self-help books and television programs are popular, but few people who are functioning well are willing to pay a clinician simply to try to increase their level of happiness. Mental disorders are fairly common, and clinicians focus on treating disorders because that is what is needed most. Working with people to reach the heights of positive mental health might even be considered a misallocation of resources considering the number of people who desperately need help but are unable to find it or afford it. For example, it is estimated that about 800,000 inmates in penal institutions have a mental disorder, and 140,000 people experiencing homelessness are seriously mentally ill (American Psychological Association, 2014; SAMHSA, 2021). As clinicians our priority should be on helping those people who have the greatest need.

While clinicians spend most of their time treating people for mental disorders, it is important to capitalize on clients’ resources as a part of treatment. Resilience is an important factor in healing, and it is well known that people vary in their ability to bounce back from challenges. If two people experience the same difficulty or trauma, one may develop a mental disorder while the other does not. An important part of helping people with disorders is to help them develop coping skills and resilience so they are less vulnerable in the future. So although clinicians begin by identifying clients’ disorders, they go on to emphasize client’s strengths and resources as an essential part of treatment.

Regarding physical health, it is understood that a pathological condition, such as an illness or broken arm, is bad, and the goal of treatment is to return the person to a state of health. The idea of psychopathology is based on differentiating normal from abnormal mental functioning. Most people would agree that extremely dysfunctional mental states are bad and thus pathological. However, normal psychological functioning is harder to define than normal physical functioning. What exactly is normal psychological functioning? If normal is used to describe the supposedly average person, then it would mean some degree of impairment, since everyone has some areas of less than healthy functioning. If normal is used to refer to what is typical or usual, then, for example, using no alcohol at all would be abnormal, since 70% of adult Americans use alcohol to some degree. If normal is considered the same as healthy, then half of all of us are abnormal, since about half the population experiences a mental disorder at some time during their lives. If normal is defined as the ideal state of optimal mental health, then most people may never reach it.

In everyday parlance, most people distinguish between being normal and having a mental illness. According to Dr. Allen Frances (2013a), who chaired the DSM-IV Task Force, it is most certainly not normal to be mentally ill, but we need to be careful not to make the definitions too loose. There may be many people with conditions that meet the DSM-5-TR criteria for a disorder, but are not severely impaired. Can a person be abnormal psychologically but not mentally ill? The statistical normal curve describes much of human diversity, but the boundaries (standard deviations) are arbitrary. Society should allow for people to be different without labeling their condition as abnormal or an illness (unless they request treatment). Every person is unique and has some eccentricities, which contribute to their personality. More people would probably do well to embrace their weirdness since there is nothing wrong with being different in itself.

In summary, the idea of normality is not particularly useful when describing mental health. The World Health Organization defines health as a state of complete physical, mental, and social well-being (WHO, 2021), but how many people achieve that state? When patients say they just want to be normal, or ask if their condition is normal, presumably they are expressing a negative evaluation of their current state and a desire to be rid of their distress. The role of the clinician is to diagnosis their condition and treat it. Clinicians spend most of their time working with clients who have a mental disorder and severe problems in living who would just like to get back to an average or more normal state of mental health.

Definition of Mental Disorder

The DSM-5 (p. 20) defined a mental disorder as a syndrome characterized by clinically significant disturbance . . . . that reflects a dysfunction in the person’s mental functioning. To qualify as a mental disorder, in most cases the condition must cause the person significant distress or impairment. An expectable response to a stressor is not a mental disorder. Socially deviant behavior and conflicts that arise between the individual and society are not mental disorders unless the deviance results from a dysfunction in the individual. For example, a person who is perceived as politically, religiously, or sexually deviant (abnormal based on the self-reported behavior of most people) cannot be assumed to be experiencing a mental disorder.

Historically, organic disorders (those resulting from biological impairment) were distinguished from functional disorders (those without known biological impairment). Psychiatry has eliminated this dichotomy, based on the assumption that all mental disorders can (or eventually will be) traced to impaired brain functioning. Some psychologists dispute this view, feeling that, for example, dysfunctional thinking is not necessarily the result of impaired neurons or neural networks, but rather learned habits of thinking. This makes sense, although of course all mental activity is, at base, physical neurological activity. People without neurological defects can still have psychological problems. The DSM-5-TR takes the view that not all mental activity is dysfunctional, but all mental disorders ultimately have a biological basis.

The DSM-IV (APA, 2000, p. xxx) stated that the term mental disorder unfortunately implies a distinction between ‘mental’ disorders and ‘physical’ disorders that implies a reductionistic anachronism of mind/body dualism even though we know that there is much that is ‘physical’ in ‘mental’ disorders and much that is ‘mental’ in ‘physical’ disorders. People are holistic beings, and talking about various parts (brain vs. mind) is simply for convenience. The DSM-IV and DSM-5-TR use the term mental disorders because no one has found an appropriate substitute.

The diagnosis of a mental disorder is not equivalent to a need for treatment, and some people with a mental disorder may not need or want treatment. Since diagnosis is inherently subjective, it is not possible to completely separate normal and pathological symptom expressions. However, most clients who seek psychotherapy probably either have a mental disorder or are very distressed about a condition that is not technically a mental disorder.

Prevalence of Mental Disorders

Much research has been conducted to estimate the prevalence of mental disorders, but precise figures should be considered tentative. About 46% of Americans will suffer from a mental disorder at some point during their lifetime. About 45 million Americans (one in five adults) have some form of mental disorder at some time, and about 11 million Americans have a serious mental disorder at any specific time (Kessler & Wang, 2008). Many mental disorders are mild and short-term, but some are very serious and chronic. Anorexia nervosa has a mortality rate of 10% by some measures, the highest of any mental disorder. Suicide, which very often is associated with a mental disorder, is the third leading cause of death among American teenagers, and is the main cause of death for people between the ages of 15 and 49 in industrialized countries. Most people who die of suicide never received any mental health care. According to the World Health Organization (2021a), more lives are claimed globally by suicide than by war, murder, state execution, and terrorist attacks combined; worldwide about one million people die of suicide every year.

In terms of lifetime prevalence, the most common mental disorder is some form of anxiety disorder (29%), followed by impulse control disorders (25%), mood disorders (21%) and substance use disorders (15%) (Kessler & Wang, 2008). In the most recent year for which data is available, anxiety disorders affected 40 million adults (18% of the adult population of the U.S.) and mood disorders affected 21 million adults (about 10% of the population) (NIMH, 2021). Nineteen million Americans have a specific phobia, and 15 million have a social phobia. Major depressive disorder affects 16 million American adults; ADHD affects nine million adults and three million children; and PTSD affects eight million adults. About seven million American adults have generalized anxiety disorder; six million have bipolar disorder; three million have persistent depressive disorder; two million have schizophrenia; and two million have obsessive-compulsive disorder (NAMI, 2021).

About 60% of Americans who have a mental disorder in any one year receive no treatment for it (Kilgus, Maxmen, & Ward, 2016). About half of people who do not seek treatment say they cannot afford it. One-third of all mental health visits involve problems too mild to qualify as a disorder. So, many of those who are most in need of treatment do not get it, and many of those who are least in need of treatment do get it. A financially secure person can afford to get therapy for a mild anxiety disorder, but a person experiencing homelessness who has schizophrenia may struggle to get assistance of any kind.

Of the people with a mental disorder who do get help, only one-third of them receive an evidence-based treatment (e.g., few people who have an anxiety disorder get cognitive-behavior therapy). Instead of getting psychotherapy, about one-third of people with a mental disorder see a spiritual, alternative, or fringe healer (these practitioners may use treatments such as herbs, acupuncture, massage, colonics, crystals, magnets, or prayer). Psychotherapists should always prioritize using evidence-based treatments when they are available, assuming the client is agreeable.

Are prevalence rates too high? Do about half of American adults really have a mental disorder? This may seem unlikely, but one should remember that mental disorders occur on a spectrum of severity. Some relatively minor conditions are considered disorders (e.g., phobias and insomnia), and some conditions are very common (e.g., substance abuse, anxiety, and depression). Also, why should mental illness be rare when physical illness is not rare? Everyone has one or more physical illnesses at some time, and it should not be surprising that almost everyone has some degree of psychological impairment at some time during their lives. The most severe mental disorders are rare (e.g., the lifetime prevalence of schizophrenia is 0.5 to 1%), but mild versions of many mental disorders are common (NAMI, 2021).

Frances (2013a) attributed the high reported rates of mental illness to loose DSM-5 definitions, disease mongering by the big pharmacological companies, careless diagnostic practices by physicians, the pressure clinicians feel from insurance companies to diagnose quickly, and flawed research on epidemiology. It is certainly true that it is very difficult to measure the prevalence of mental disorders. The debate over how to define mental health and mental disorder highlights the subjectivity and complexity of diagnosis. Mental disorders are serious conditions, and they should not be conflated with everyday distress (Frances, 2013a).

About 60% of people who have one mental disorder also have another mental disorder (co-morbidity). Mood disorders are considered more serious than anxiety disorders; depressed people sometimes die by suicide, but hardly anyone dies of anxiety. The most common serious mental disorder is major depressive disorder. The mental disorder with the highest mortality rate is anorexia, but anorexia is a relatively uncommon mental disorder, with a lifetime prevalence of 0.6% (NIMH, 2021).

Because mental disorders are fairly common, it is not surprising that many famous people have had a disorder. For example, it is thought that several U.S. presidents had a mental disorder (Davidson, Connor, & Swartz, 2006). Thomas Jefferson had social phobia; James Madison experienced depression; Abraham Lincoln had major depression; Theodore Roosevelt had bipolar disorder; Richard Nixon had an alcohol use disorder; Ronald Reagan had some symptoms of Alzheimer’s disease while in office; and George W. Bush had an alcohol use disorder as a young adult. Barack Obama had a tobacco use disorder, and it has been suggested that Donald Trump may have narcissistic personality disorder (Lee, 2017). In general, having a mental disorder (or a physical illness or disability) in itself does not disqualify a person from public service.

Why Diagnose Mental Disorders?

The word diagnosis comes from Greek and Latin words (via gnosis) meaning a way of knowing. The reason to know (diagnose) a client’s mental disorder is to help them deal with and possibly overcome it. Diagnosis should never be used to harm people. An accurate diagnosis is necessary to provide information that informs treatment. The idea is that you can’t treat what you can’t name. If there were only one effective treatment for all mental disorders, then diagnosis would be irrelevant, since every patient would receive the same treatment. But there are many mental disorders that vary in many ways, and some treatments are more effective than others for specific mental disorders.

Some clinicians have suggested that diagnosis is not necessarily directly related to treatment. For example, there is no one treatment that is best for patients who have a major depressive disorder. However, some treatments do have much better evidence for their effectiveness with major depression than others, so they would be the treatments of choice if other factors are equal. Some clinicians who hold strongly to one theoretical model do basically the same kind of treatment for all their patients, or only accept patients with certain kinds of problems. For them the diagnostic process might not be very important. For example, psychodynamic and client-centered therapists do the same kind of therapy for all anxious clients, and do not use the behavioral treatments that have been found to be effective for anxiety (e.g., relaxation training or exposure and response prevention). However, most psychotherapists are eclectic, and are open to using a wide variety of techniques that have evidence of their safety and effectiveness.

Although the main purpose of diagnosis is to help clients by identifying a mental disorder so appropriate treatment can be provided, there is another good reason for diagnosis. A reliable diagnostic system is essential for clinicians to share a common language. Clinicians can use diagnostic terms (e.g., bipolar, OCD, PTSD) to communicate with each other efficiently. Diagnostic terms also facilitate research on epidemiology and many other areas of research in mental health.

The DSM-5-TR system is modeled on the work of German psychiatrist Emil Kraepelin (1856-1926), who designed the first major nosology (classification) of mental disorders. In his system diagnosis was based on categorical descriptive criteria and did not address etiology (the cause of disorders). A descriptive approach provides a good way to think about the characteristics of mental disorders without worrying too much about their causes, which are unknown in most cases.

Signs, Symptoms, and Syndromes

Psychopathology manifests as signs (which are objective) and symptoms (which are subjective). Signs can be observed and documented objectively; for example, an observer (or video camera) can see that a client is smiling or looking down at the floor or fidgeting. Symptoms are verbal reports. Signs carry more weight than symptoms, since they are objective. For example, if a client denies feeling sad but cries easily while describing a problem, the client is probably sad. This would just be a hypothesis, and much more information would be needed to make a diagnosis of depression.

Symptoms are experienced subjectively, cannot be observed, and must be reported by the client. Examples of symptoms include anxiety, pain, depressive thoughts, and hallucinations. Depressed mood is a symptom, while crying is a sign. People can have a symptom without having a mental disorder. Mental disorders usually have several symptoms, but having one symptom rarely constitutes a mental disorder. Everyone has issues of concern and problems in living, but not everyone has symptoms of a disorder. One way to think of this is that issues contain ideas and symptoms do not, although symptoms can express ideas.

Syndromes are combinations of symptoms, signs, and events that occur together in a pattern and suggest a certain disorder. For example, a patient who cries easily and complains of having a very sad and hopeless mood, but only during the dark winter months, may have seasonal affective disorder. With experience clinicians learn how signs and symptoms group together to constitute mental disorders.

Clinical Disorders vs. Personality Disorders

The great majority of the DSM-5-TR describes the clinical mental disorders, including psychotic disorders, anxiety disorders, depressive disorders, and many others. These disorders tend to be acute and florid, and most are responsive to treatment. One chapter of the DSM-5-TR describes ten personality disorders. Personality refers to ingrained patterns of thinking, feeling, and behaving, and these disorders tend to be chronic, consistent, developmental, and may be more resistant to treatment than clinical disorders. Although everyone has a personality style, only some people have a personality disorder. The DSM-IV separated clinical disorders from the personality disorders on different axes, but the DSM-5 eliminated this distinction. Clinicians should always try to identify the personality style of the client, consider whether the client has a personality disorder, and see the client’s mental disorder within the context of their personality. Theodore Millon’s books are excellent guides for developing skill in this area (e.g., Millon, 2004).

How Many Mental Disorders Are There?

In most ancient writings, all conditions that we consider mental illness today were called madness or a similar general term. In Europe by the year 1699 it was thought that there were three disorders (melancholy, mania, and dementia), and by 1880 four other conditions had been added (paranoia, idiocy, imbecility, and epilepsy). In 1904 Emil Kraepelin included 15 conditions in his nosology, and the first diagnostic classification of the American Psychiatric Association had 22 different disorders.

The first edition of the Diagnostic and Statistical Manual of the APA was published in 1952 and included 106 disorders. The DSM-II (1968) had 182 disorders, the DSM-III (1980) had 265 disorders, and the DSM-III-R (revised) (1987) had 292 disorders. The DSM-IV (1994) had 197 disorders, and the DSM-IV-TR (2000) had 197