Dimensional and Cross‐Cutting Assessment in the DSM‐5

A significant proposed change to the 5th edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM‐5) that will significantly affect the way counselors diagnose mental disorders is the addition of dimensional assessments to the categorical diagnoses. The author reviews the current DSM's (4th ed., text rev.; American Psychiatric Association, 2000 ) categorical classification system, describes the proposed dimensional and cross‐cutting assessments, and provides implications about clinical utility and user acceptability of a dimensional diagnostic approach.     

Moral/non‐moral domain shift in young adolescents in relation to delinquent behaviour

Because moral transgressions are considered more serious than non‐moral (i.e. conventional or personal) transgressions, it is less threatening to self‐esteem to interpret one's own delinquent act as a non‐moral transgression rather than a moral transgression. This ‘domain shift’ could be a way of reducing cognitive dissonance. It was expected that adolescents who report a certain category of delinquent behaviour would evaluate hypothetical transgressions in the same category as more non‐moral than would adolescents who did not report that category of delinquent behaviour. A group of 278 students from the first (M(age)=13.1), second (M(age)=14.3) and third (M(age)=15.2) grade of intermediate secondary schools in the Netherlands participated in the research. The results showed a domain shift from the moral towards non‐moral domains in the evaluation of hypothetical situations about delinquent behaviour reported by the adolescent. At the same time, this domain shift did not occur in situations concerning delinquent behaviour not reported by the adolescent, even when delinquent behaviour occurred in the adolescent's peer group. This finding is consistent with the hypothesis that the domain shift takes place as a consequence of cognitive dissonance. The results also showed that the attitude towards delinquent behaviour and the prevalence of delinquent behaviour in the peer group both predicted a unique part of the variance in reported delinquent behaviour (RDB; 28% and 10%, respectively). The level of moral reasoning (measured by the Sociomoral Reflection Measure–Short Form [SRM‐SF]) did not appear to be a significant predictor of RDB.     

The Unstructured Clinical Interview

In mental health, family, and community counseling settings, master's‐level counselors engage in unstructured clinical interviewing to develop diagnoses based on the Diagnostic and Statistical Manual of Mental Disorders (4th ed., text rev.; DSM‐IV‐TR; American Psychiatric Association, 2000). Although counselors receive education about diagnosis and the DSM classification system, the majority of them are not specifically trained in clinical interviewing. This article provides information about using the unstructured clinical interview to make a DSM‐IV‐TR diagnosis for adult clients with Axis I and Axis II disorders.     

Anxiety sensitivity cognitive concerns drive the relation between anxiety sensitivity and symptoms of depression

Depression is typically treated as a homogeneous construct despite evidence for distinct cognitive, affective, and somatic symptom dimensions. Anxiety sensitivity (AS; the fear of consequences of anxiety symptoms) is a cognitive risk factor implicated in the development of depressive symptoms. However, it is unclear how lower order AS dimensions (i.e. physical, cognitive, and social concerns) relate to depressive symptom factors. Confirmatory factor analysis, followed by structural equation modeling, were conducted to examine the factor structure of depression and to then examine the relations between these factors and the lower order factors of AS. This study was conducted in a sample of 374 adults (M age = 35.5, 54.3% female) with elevated levels of psychopathology (89.2% meeting criteria for at least one DSM-5 diagnosis, 25.6% primary depressive disorder). In this study a two-factor model of depression, composed of Cognitive and Affective/Somatic factors, was superior to one- and three-factor solutions. AS cognitive concerns were related to both cognitive and affective/somatic symptoms of depression. Neither of the other AS dimensions was related to depression symptom dimensions. These findings provide a better understanding of the relations between AS and depression symptoms.     

Stimulus–response translation in manual and vocal modality: Is age‐related slowing influenced by changes in working memory functioning?

In some conditions, age‐related slowing rates are higher for manual than for vocal responses. The interaction between age and response modality was examined in four experiments in which the performance of younger (M = 22.6 years) and older (M = 70.8 years) adults was compared under various stimulus–response mapping rules. The interaction effect was not observed in a simple localisation task on which the manual modality had an advantage in both age groups (Experiment 1). When congruence between stimulus and response was reduced (Experiment 2), manual responses were disproportionately slowed in older participants. In conceptual and size comparison tasks (Experiment 3), the age‐by‐modality effect was not influenced by working memory load during the interval between the first and the second stimulus presentation. In an identification task, age‐related slowing effects were less when responses were spoken names than when nonwords were used as labels (Experiment 4). These results indicate that older participants experience a specific difficulty in activating arbitrary S–R mapping rules during executive control.     

Personality Disorders Are Not as We Thought: Hierarchical Factor Structure at the Criterion Level

The use of personality disorder (PD) categories persists, despite the evidence against them. An often overlooked reason for this is the fact that the true structure underlying the Diagnostic and Statistical Manual of Mental Disorders (DSM) taxonomy is still unknown: We cannot be certain which disorders are valid, and which ones are arbitrary mixtures of heterogeneous traits. To address this gap, we factor analyzed the Personality Diagnostic Questionnaire (PDQ–4+; Hyler, 1994 Hyler, S. E. (1994). PDQ–4+ Personality Diagnostic Questionnaire–4+. New York, NY: New York State Psychiatric Institute. [Google Scholar]) at the criterion level in a mixed clinical and nonclinical sample of 2,519 individuals. The resulting structure was more similar to current dimensional taxonomies than to the DSM classification at all hierarchical levels. Whereas paranoid and antisocial PDs—and to a lesser extent avoidant, dependent, depressive, and schizoid PDs—were fairly homogeneous, all other disorders turned out to be combinations of 2 or 3 unrelated dimensions. Our results strongly support the structure of empirically based dimensional taxonomies and relocate DSM criteria within this emerging framework, thus contributing to preserving much of the knowledge accumulated to date.     

Associations between lower order anxiety sensitivity dimensions and DSM-5 posttraumatic stress disorder symptoms

Anxiety sensitivity (AS), a well-established individual difference variable reflecting a tendency to fear bodily sensations associated with arousal, has been implicated in the development and maintenance of posttraumatic stress disorder (PTSD). Despite these associations, little research has examined the relations between AS subfactors (eg physical, cognitive, and social) and PTSD symptoms and none have examined these associations in the context of DSM-5 (Diagnostic Statistical Manual of Mental Disorders, Fifth Edition) PTSD clusters (ie intrusion, avoidance, negative alterations in cognitions/mood, and arousal). Participants included 50 veterans presenting to an outpatient Veteran Affairs Clinic for psychological services. Upon intake, veterans completed a brief battery of self-report questionnaires to assist with differential diagnosis and treatment planning. Results revealed unique associations between lower order AS dimensions, in particular the cognitive concerns dimension, and all four DSM-5 PTSD symptom clusters. Given the malleable nature of AS cognitive concerns, as well as the growing number of veterans in need of care, future research should determine the extent to which targeting this cognitive risk factor reduces PTSD symptom severity among veterans.     

Independent Effects of Mental Disorders on Suicidal Behavior in the Community

This study assessed the independent contributions of nine common mental disorders on suicide ideation and suicide attempt. A community‐based survey of Australian adults (N  = 3,175) was conducted to identify common mental disorders associated with recent suicide attempt. Nine disorders were assessed using DSM ‐5 clinical criteria. Logistic regression models indicated that all disorders were significantly and independently associated with suicide ideation. However, only obsessive‐compulsive disorder and posttraumatic stress disorder were significantly associated with suicide attempt among participants with ideation, independently of other disorders (OR = 2.0 for both). Increasing comorbidity had a significant monotonic association with suicide ideation but not attempts.     

Towards the DSM‐5 Criteria for Autism: Clinical,Cultural, and Research Implications

The new edition of the DSM is proposing significant changes to current diagnostic definitions of autism and related conditions. In this article, we will discuss the clinical, research, and cultural implications of these changes. We conclude that the new criteria appear to better reflect current understanding of the autism spectrum disorder than the current DSM‐IV criteria. As expected with any major change in classification systems, there are also significant risks, which will have to be carefully monitored and addressed by both policy makers and the scientific community to ensure that best clinical practice and research are facilitated and advanced.     

Analogue Measures of DSM-IV Mood and Anxiety Disorders Based on Behavior Checklists

Although symptom checklists are commonly used to assess childpsychopathology, confusion arises due to differences between empirically derived checklist syndromes and rationally derived DSM-IV diagnostic categories. This paper explores analogue measures of DSM-IV mood and anxiety disorders created using items from the Youth Self-Report and Child Behavior Checklist (T. M. Achenbach, 1991a, 1991b) that parallel DSM-IV symptoms. In a matched sample of clinically referred and nonreferred adolescents, analogue measures demonstrated expected patterns of age differences, sex differences, and comorbidity. Meeting criteria for an analogue diagnosis was also associated with referral for mental health services and poor social competence. Informant effects are highlighted and the potential benefits and limitations of using existing behavior checklists to assess DSM disorders are discussed. These findings suggest the utility of checklists in identifying analogues of anxiety and mood disorders in children and adolescents.     

A brief historicity of the <Emphasis Type="Italic">Diagnostic and Statistical Manual of Mental Disorders</Emphasis>: Issues and implications for the future of psychiatric canon and practice

The Diagnostic and Statistical Manual (DSM) of the American Psychiatric Association, currently in its fourth edition and considered the reference for the characterization and diagnosis of mental disorders, has undergone various developments since its inception in the mid-twentieth century. With the fifth edition of the DSM presently in field trials for release in 2013, there is renewed discussion and debate over the extent of its relative successes - and shortcomings - at iteratively incorporating scientific evidence on the often ambiguous nature and etiology of mental illness. Given the power that the DSM has exerted both within psychiatry and society at large, this essay seeks to analyze variations in content and context of various editions of the DSM, address contributory influences and repercussion of such variations on the evolving landscape of psychiatry as discipline and practice over the past sixty years. Specifically, we document major modifications in the definition, characterization, and classification of mental disorders throughout successive editions of the DSM, in light of shifting trends in the conceptualization of psychopathology within evolving schools of thought in psychiatry, and in the context of progress in behavioral and psychopharmacological therapeutics over time. We touch upon the social, political, and financial environments in which these changes took places, address the significance of these changes with respect to the legitimacy (and legitimization) of what constitutes mental illness and health, and examine the impact and implications of these changes on psychiatric practice, research, and teaching. We argue that problematic issues in psychiatry, arguably reflecting the large-scale adoption of the DSM, may be linked to difficulties in formulating a standardized nosology of psychopathology. In this light, we highlight 1) issues relating to attempts to align the DSM with the medical model, with regard to increasing specificity in the characterization of discrete mental disease entities and the incorporation of neurogenetic, neurochemical and neuroimaging data in its nosological framework; 2) controversies surrounding the medicalization of cognition, emotion, and behavior, and the interpretation of subjective variables as 'normal' or 'abnormal' in the context of society and culture; and 3) what constitutes treatment, enablement, or enhancement - and what metrics, guidelines, and policies may need to be established to clarify such criteria.     

A Tricky Object to Classify: Evidence,Postpartum Depression and the DSM‐IV

The concept of evidence has become central in Western healthcare systems; however, few investigations have studied how the shift toward specific definitions of evidence actually occurred in practice. This paper examines a historical case in psychiatry where the debate about how to define evidence was of central importance to nosological decision making. During the fourth revision of the Diagnostic andStatistical Manual of Mental Disorders a controversial decision was made to exclude postpartum depression (PPD) as a distinct disorder from the manual. On the basis of archival and interview data, I argue that the fundamental issues driving this decision were related to questions about what constituted suitable hierarchies of evidence and appropriate definitions of evidence. Further, although potentially buttressed by the evidence‐based medicine movement, this shift toward a reliance on particular kinds of empirical evidence occurred when the dominant paradigm in A merican psychiatry changed from a psychodynamic approach to a research‐based medical model.     

Effectiveness of the MMPI-2-RF Validity Scales for Feigned Mental Disorders and Cognitive Impairment: A Known-Groups Study

The MMPI and MMPI-2 validity scales have long been accepted as standard tools in the assessment of feigned mental disorders (FMD) based on their extensive empirical validation. Studies are now examining MMPI-2-RF with modified validity scales plus the new Infrequent Somatic Responses Scale (F_S) and the recently-adapted Response Bias Scale (RBS). The current investigation used a known-groups design to examine the effectiveness of the MMPI-2-RF for differentiating FMD and feigned cognitive impairment (FCI) from patients with genuine disorders for a large civil forensic sample. Criterion measures included the Structured Interview of Reported Symptoms-2 (SIRS-2) for the FMD group, and below-chance performances on the Victoria Symptom Validity Test (VSVT) and the Test of Memory Malingering (TOMM) for the FCI group. For FMD, both F-r and F_P-r produced very large effect sizes (ds > 2.00). Moreover, the absence of severe elevations (≥80 T) on F-r proved effective at ruling-out most FMD. For the current study, a F_P-r cut score ≥90 T for FMD produced virtually no false-positives (0.01) and only a moderate level of false-alarms. As predicted by its detection strategies, most MMPI-2-RF validity scales have limited effectiveness with the FCI group. However, FBS-r and RBS may be useful in conjunction with other clinical data for ruling out FCI for genuine neuropsychological consults. An entirely separate concern is whether certain diagnostic groups, such as major depression, will have marked elevations on MMPI-2-RF scales thereby increasing the likelihood of false-positives. On this point, F_P-r performed exceptionally well with unelevated scores (Ms < 55 T) consistently across diagnostic categories.     

Concurrent Validity of the Child Behavior Checklist DSM-Oriented Scales: Correspondence with DSM Diagnoses and Comparison to Syndrome Scales

This study used receiver operating characteristic (ROC) methodology and discriminative analyses to examine the correspondence of the Child Behavior Checklist (CBCL) rationally-derived DSM-oriented scales and empirically-derived syndrome scales with clinical diagnoses in a clinic-referred sample of children and adolescents (N = 476). Although results demonstrated that the CBCL Anxiety, Affective, Attention Deficit/Hyperactivity, Oppositional and Conduct Problems DSM-oriented scales corresponded significantly with related clinical diagnoses derived from parent-based structured interviews, these DSM-oriented scales did not evidence significantly greater correspondence with clinical diagnoses than the syndrome scales in all cases but one. The DSM-oriented Anxiety Problems scale was the only scale that evidenced significantly greater correspondence with diagnoses above its syndrome scale counterpart —the Anxious/Depressed scale. The recently developed and rationally-derived DSM-oriented scales thus generally do not add incremental clinical utility above that already afforded by the syndrome scales with respect to corresponding with diagnoses. Implications of these findings are discussed.     

Theodore Millon's Contributions to Conceptualizing Personality Disorders

We review Theodore Millon's contributions to conceptualizing personality disorders in contemporary clinical science and practice. Millon worked tirelessly across professional domains and theoretical orientations, developing a rich integrative theory of personality and its pathology, directly and indirectly impacting the evolving iterations of the Diagnostic and Statistical Manual of Mental Disorders (DSM–III through DSM–5), and advocating for the personality disorders through his contributions to cofounding the International Society for the Study of Personality Disorders and the Journal of Personality Disorders. We conclude with a closer look at Millon's final major contributions to conceptualizing personality disorders as well as the strengths and limitations of his approach.     

The Effectiveness of the MMPI-2-RF in Detecting Feigned Mental Disorders and Cognitive Deficits: a Meta-Analysis

A cornerstone of forensic assessments involves the assessment of response styles, including feigning and malingering. As a forensic relevant instrument (FRI), the Minnesota Multiphasic Personality Inventory-2-Restructured Form (MMPI-2-RF) contains embedded overreporting scales that cover the three major domains: feigned mental disorders (i.e., F-r and Fp-r), feigned cognitive impairment (RBS and FBS-r), and feigned medical complaints (Fs). This meta-analytic review of 30 studies examined the effectiveness of various detection strategies and cut scores for the MMPI-2-RF. As an important clinical concern, several feigning scales (F-r, FBS-r, and RBS) exhibited marked elevations (Ms > 80 T) for genuine responders diagnosed with major depressive or somatoform disorders. However, the Fp-r—a true rare-symptoms detection strategy—proved highly effective for discriminating feigned from genuine psychopathology (ds > .90). For feigned cognitive impairment, the FBS-r produced very large effect sizes with feigned TBI (M d = 1.41); however, its cut scores were more indicative of general feigning than feigned cognitive impairment. Finally, Fs yielded a large effect size (d = 1.23) for feigned medical complaints, but its cut scores were more likely to identify examinees feigning mental disorders (M sensitivity = .74) than medical complaints (M sensitivity = .43). These findings are discussed within the context of clinical forensic evaluations.     

Anxiety Disorders in Childhood: Casting a Nomological Net

Empirical research highlights the need for improving the childhood anxiety disorder diagnostic classification system. In particular, inconsistencies in the stability estimates of childhood anxiety disorders and high rates of comorbidity call into the question the utility of the current DSM criteria. This paper makes a case for utilizing a nomological net⁴ model for advancing the understanding of childhood anxiety disorders. In this article, we discuss measurement and assessment issues related to improving the childhood anxiety disorder diagnostic system and show how these issues can be addressed by employing the nomological net of childhood anxiety. Because employing the nomological net involves drawing from etiological process theories to facilitate classification and assessment, an integrative model of childhood anxiety disorders is presented as a tentative heuristic. Then evidence for the existing symptom sets is discussed in the context of how process theory mechanisms may be utilized to improve classification and assessment. Testable hypotheses are presented. Measurement, disorder definition, treatment, and policy implications are also discussed.A nomological net can be briefly defined as the theoretical structure of a construct.     

That Way Madness Lies: At the Intersection of Philosophy and Clinical Psychology

Abstract: I argue that philosophical practice is a clinically active and influential endeavor, with both positive (therapeutic) and negative (detrimental) psychological possibilities. Though some have explicitly taken the clinical aspects of philosophy into the therapeutic realm via the new field of philosophical counseling, I am interested in the clinical context of philosophers as philosophers, engaged in standard, philosophical pursuits. In arguing for the clinical implications of philosophical practice I consider the relation between philosophical despair and depression, the cognitive etiology of depression and other clinical disorders, selected DSM‐IV entries, attribution theory, and cognitive therapy.     

Older (but not younger) preschoolers understand that knowledge differs between people and across time

We examined 3‐ to 5‐year‐olds' understanding of general knowledge (e.g., knowing that clocks tell time) by investigating whether (1) they recognize that their own general knowledge has changed over time (i.e., they knew less as babies than they know now), and (2) such intraindividual knowledge differences are easier/harder to understand than interindividual differences (i.e., Do preschoolers understand that a baby knows less than they do?). Forty‐eight 3‐ to 5‐year‐olds answered questions about their current general knowledge (‘self‐now’), the general knowledge of a 6‐month‐old (‘baby‐now’), and their own general knowledge at 6 months (‘self‐past’). All age groups were significantly above chance on the self‐now questions, but only 5‐year‐olds were significantly above chance on the self‐past and baby‐now questions. Moreover, children's performance on the baby‐now and self‐past questions did not differ. Our findings suggest that younger preschoolers do not fully appreciate that their past knowledge differs from their current knowledge, and that others may have less knowledge than they do. We situate these findings within the research on knowledge understanding, more specifically, and cognitive development, more broadly.