PS440 Unit 3 Classification and Assessment Paper Example

Four Diagnoses or One Problem: A PS440 Unit 3 Classification and Assessment Paper

[Student Name]

Purdue University Global

PS440: Psychopathology

Unit 3 Classification and Assessment Paper

[Instructor Name]

[Date]

The guest and the crisis center are composite; the manual, field trials and frameworks cited are real.

The Guest

Dale is a 38-year-old kiln operator at a cement plant near Rapid City, South Dakota. He arrived at the crisis center after his wife found him sitting in his truck in the garage with the engine off, unable to explain why he was there. He was not suicidal, he said, just unable to go inside.

Over three days, the center's counselor gathered a long history. For about two years Dale's mood has stayed flat and gray, hunting and fishing no longer appeal to him, and slept badly. He worries constantly about money, his health and his children, and cannot stop. He has had several sudden episodes of a pounding heart and shaking at work, which he calls spells. He drinks a twelve-pack most weekend nights and several beers on weeknights, and he has missed shifts after drinking. He is irritable and has punched a wall twice this year. Eight years ago he pulled a coworker from a kiln fire and still has nightmares about it a few times a month.

Depending on how the counselor weighed this history, Dale could receive four DSM diagnoses: persistent depressive disorder, generalized anxiety disorder, alcohol use disorder and possibly posttraumatic stress disorder, with panic attacks noted as a specifier. This paper asks what that list tells us and what alternative systems would say instead.

The DSM's Categories

The DSM-5-TR classifies mental disorders as categories, each defined by a set of criteria, a required number of symptoms and a minimum duration (American Psychiatric Association, 2022). The categorical approach has clear strengths. It gives clinicians a shared language, guides treatment research, which is organized around diagnoses, and determines insurance coverage. For Dale, it would justify treatment for his drinking, mood and anxiety and allow his care to be billed.

The weaknesses are equally visible in his case. Four diagnoses suggest four separate problems, yet the counselor's impression was of one man whose distress shows up in several ways. Categories also force yes-or-no decisions. Dale's nightmares about the kiln fire are frequent but not constant, and whether they meet the threshold for PTSD depends on how one counts avoidance. A small change in his answers would add or remove a diagnosis without any change in Dale.

How Reliable Are the Categories?

Reliability means that two clinicians assessing the same person would arrive at the same diagnosis. Regier et al. (2013) reported the test-retest reliability of DSM-5 diagnoses in field trials at academic and clinical sites in the United States and Canada. Some diagnoses showed good agreement between clinicians, including PTSD. Agreement was only questionable for others, and major depression and generalized anxiety, two of the labels closest to Dale's complaints, were among them. Alcohol use disorder fell in between.

Two of the diagnoses most likely to appear on Dale's chart are among those clinicians in the DSM-5 field trials agreed on least often.

These results do not mean that depression and anxiety are not real. Low reliability is a property of the definitions and of how interviews are conducted, not proof that the suffering is imagined. They show that the boundaries drawn around them are hard to apply consistently, especially when symptoms overlap. For a person like Dale, two clinicians might reasonably assign different combinations of diagnoses.

A Dimensional Alternative: HiTOP

The Hierarchical Taxonomy of Psychopathology, or HiTOP, was proposed by a consortium of researchers as a dimensional alternative to traditional categories (Kotov et al., 2017). Instead of treating disorders as separate categories, HiTOP organizes symptoms into a hierarchy based on how they actually occur together in large samples. At the top sit a few broad spectra. One, internalizing, gathers depression, anxiety and trauma-related distress; another, disinhibited externalizing, gathers substance use and impulsivity. Below them are subfactors and narrower syndromes and traits. People are described by their level on each dimension rather than by the presence or absence of a disorder.

HiTOP would describe Dale more simply. He is high on the internalizing spectrum, particularly the distress subfactor that groups depression, generalized anxiety and PTSD symptoms, and moderately high on disinhibited externalizing because of his drinking and anger. That description explains why his four diagnoses co-occur: they are expressions of two underlying dimensions. It also suggests treatment that targets shared processes, such as a transdiagnostic therapy for emotional disorders, rather than four separate protocols.

HiTOP has limits. Its measures are still being developed for routine clinical use, insurance systems are built on DSM codes, and dimensions require cutoffs when a clinician must decide whether to treat.

A Research Framework: RDoC

RDoC, the Research Domain Criteria launched by NIMH, takes another approach (Insel et al., 2010). It was designed as a framework for research rather than a clinical system. RDoC organizes study around domains of functioning, such as negative valence systems, which include responses to threat and loss, and arousal and regulatory systems, examined across units of analysis from genes and circuits to behavior and self-report. Its developers hoped that research organized this way would eventually produce classifications based on causes rather than symptom lists.

For Dale, RDoC would not provide a diagnosis. A researcher might study his heightened threat responses, linking his worry, his spells and his nightmares to activity in brain threat circuits, and his reward responses, linking loss of interest and heavy drinking. That perspective is promising for understanding mechanisms, but it offers his counselor nothing to bill and little to guide treatment today.

What the Comparison Shows

Each system answers a different question. The DSM asks which named disorders a person has and is built for communication, research recruitment and payment. HiTOP asks where a person stands on empirically derived dimensions and fits the way symptoms co-occur. RDoC asks which biological and behavioral systems are disrupted and is built to guide research. For Dale, the DSM gave a list that was necessary for care but misleading about its structure; HiTOP gave a better picture of the person; RDoC pointed toward future understanding.

Conclusion

Dale's case shows why classification is one of the most debated topics in psychopathology. His four possible diagnoses reflect real suffering but also the limits of categories, some of which show only questionable reliability. Dimensional and research frameworks describe him in ways that fit his symptoms better, though they are not yet ready to replace the system that pays for his care.

References

American Psychiatric Association. (2022). Diagnostic and statistical manual of mental disorders (5th ed., text rev.). https://doi.org/10.1176/appi.books.9780890425787

Insel, T., Cuthbert, B., Garvey, M., Heinssen, R., Pine, D. S., Quinn, K., Sanislow, C., & Wang, P. (2010). Research domain criteria (RDoC): Toward a new classification framework for research on mental disorders. American Journal of Psychiatry, 167(7), 748-751. https://doi.org/10.1176/appi.ajp.2010.09091379

Kotov, R., Krueger, R. F., Watson, D., Achenbach, T. M., Althoff, R. R., Bagby, R. M., Brown, T. A., Carpenter, W. T., Caspi, A., Clark, L. A., Eaton, N. R., Forbes, M. K., Forbush, K. T., Goldberg, D., Hasin, D., Hyman, S. E., Ivanova, M. Y., Lynam, D. R., Markon, K., ... Zimmerman, M. (2017). The Hierarchical Taxonomy of Psychopathology (HiTOP): A dimensional alternative to traditional nosologies. Journal of Abnormal Psychology, 126(4), 454-477. https://doi.org/10.1037/abn0000258

Regier, D. A., Narrow, W. E., Clarke, D. E., Kraemer, H. C., Kuramoto, S. J., Kuhl, E. A., & Kupfer, D. J. (2013). DSM-5 field trials in the United States and Canada, Part II: Test-retest reliability of selected categorical diagnoses. American Journal of Psychiatry, 170(1), 59-70. https://doi.org/10.1176/appi.ajp.2012.12070999