Basic Psychiatric Terms and Concepts

• Author: Hy Bloom, Richard D Schneider
• Pages: 5-48

5

chapter one

Basic Psychiatric Terms and Concepts

The purpose of this chapter is to introduce basic terms and concepts with-

in the discipline of psychiatry as they arise in the course of dealing with

mentally disordered accused. The list of def‌i nitions for medical and mental

disorders, symptoms, treatments, psychological tests, and other investiga-

tive procedures and laboratory tests contained in this c hapter is far from ex-

haustive; it covers the terms legal practitioners are most likely to encounter

when working in this f‌ield.

A. DIAGNOSTIC AND STATISTICAL MANUAL OF MENTAL DISORDERS

(DSM-5)

Analogous to the case with almost all medical disorders, classif‌ication of

psychiatric conditions and setting out the clinical criteria that def‌ine the

condition is an evolving process. Determini ng whether a proposed condition

has suff‌iciently def‌inable features to achieve a threshold for consideration

as a syndrome or diagnosis generally results from the collection, synthesis,

and critical appraisal of subst antial amounts of information derived from re-

views of published literature, analyses and re- analyses of collected data, and

f‌ield trials. Work groups that collect this d ata ultimately report to a task force

which submits its recommendations for approval to the American Psychiat-

ric Association’s Committee on Psychiatric Diag nosis and Assessment.

What constitutes a mental disorder is never f‌ixed and immutable, and

in fact, can change with the course of time to ref‌lect not only new science

in the f‌ield, but also changes in the social landscape. Homosexuality is

the most frequently cited example. It was considered a psychiatric disorder

over the tenure of an earlier edition of the Diag nostic and Statistical Manual

6MENTAL DISORDER AND THE LAW

of Mental Disorders1 (DSM), but was delisted in 1973 following an Amer-

ican Psychiatric Association plebiscite on the subject, inspired in part by a

change in our (then incomplete) understanding of huma n sexuality, and by

several years of demonstrations by gay activists at annual meetings of the

America n Psychiatric A ssociation.

The Diagnosti c and Statistical Manual of Mental D isorders has gone through

seven revisions — some minor and some major — since the f‌irst edition was

published in 1952 .2 DSM I and DSM II, both of which predate an ex plosion of

research into the biological basis of psychiatric conditions, were very psycho-

dynamic in their approach. The etiology (or origin) of psychiatric disorders

was thought more likely to have its roots in upbringing and environmental

events than in neurochemical dysfunction. Cruder distinctions, for example,

between psychosis and neurosis dominated t hese earlier editions of the DSM,

although, again, both were seen as problems emanating from the person’s

upbringing and psychology, and not as disturbances based in their biology.

Psychoses represented breaks with reality frequent ly associated with hallucin-

ations and delusions, whereas neuroses were thought of as milder mental dis-

orders, typically characterized by depression and anxiety, which at the most,

involved minor distortions of real ity.

In the third edition of the DSM,3 the psychodynamic model was sup-

planted by the biopsychosocial model. Seven years later, DSM III-R4 revised

a number of the criteria for mental disorders listed in DSM III.

DSM IV-TR is the acronym for the Diagnostic and Statistical Manual of

Mental Disorders, 4th edition, Text Revision.5 It replaced DSM IV,6 to which

it was fundamentally sim ilar.

DSM IV-TR’s mission statement, as it were, was to:

◆foster uniformity and cla rity in its diagnostic approach to a patient;

1 American Psyc hiatric Association , Diagnostic and S tatistical Manual of Me ntal Disorders,

2d ed (Washington , DC: American Psychiat ric Association, 1968) [DSM II].

2 American Psychiatr ic Association, Diagn ostic and Statisti cal Manual of Mental Diso rders

(Washington, DC : American Psychiatr ic Association, 1952) [DSM I].

3 American Psych iatric Association, Di agnostic and Sta tistical Manual of Ment al Disorders,

3d ed (Washington, D C: American Psychiat ric Association, 1980) [DSM III].

4 American Psych iatric Association, Di agnostic and Stat istical Manual of Ment al Disorders,

3d ed, revised ( Washington, DC: America n Psychiatric Associat ion, 1987) [DSM III-R].

5 American Psych iatric Association, Di agnostic and Sta tistical Manual of Ment al Disorders,

4th ed, text rev ision (Washington, DC: Ame rican Psychiatric A ssociation, 2000) [DSM

IV-TR].

6 American Psyc hiatric Association , Diagnostic and S tatistical Manual of Me ntal Disorders,

4th ed (Washing ton, DC: American Psychi atric Association, 1994) [DSM IV ].

Chapter One: Basic Psychiatric Terms and Concepts7

◆create a common language and operational criteria to ensure inter-

rater consistency amongst clinicians;

◆provide to the extent possible, research-based inclusion criteria for

the var ious psychiatric conditions;

◆serve as an educational tool, providing desc riptive narratives that pre-

cede the diagnostic cr iteria for any condition as well as reviewi ng the

condition, its course, prevalence, associated features, familial pat tern,

and diffe rential diagnosis; a nd

◆provide a multiaxial coding system that describes the interrelation-

ships amongst conditions (mental, characterological and physical) th at

have impacted the individual’s current and longitudinal functioning

(Axis I, II & III, respectively); considers current stressors that have im-

plications for diagnosis, treatment and prognosis (Axis I V); and allows

for the rating of the individual’s current level of fu nctioning (Axis V, or

Global Assessment of Functioning (GAF)).

The multiaxial diagnostic scheme that was commonplace in psychiatric

reports and which courts had become familiar with was, over time, elim-

inated7 with the int roduction of DSM-5.8 The change was in part prompted

by increased research and clinica l attention into personality disorders and a

deeper understanding t hat the dividing line between personality pathology

and some major mental disorders is more f‌luid than rigid.

The American Psychiatric Association (APA) Committees charged with

revising the DSM concluded, based on a series of studies, t hat DSM IV-TR’s

diagnostic categories and criteria were too narrow and failed to ref‌lect the

reality of important links bet ween clusters of disorders.

In this regard, research demonstrated two t ypes of clusters of disorders:

the internalizing cluster or group refers to patients who experience promin-

ent anxiety, depression, and somatic symptoms. The externalizing group in-

cludes disorders that feature prominent impulsivity, substance abuse, and

disruptive conduct. The clustering better explains comorbidity of disorders

within the cluster; the disorders within the internalizing and externalizing

groups have consequently been strategically located adjacent to each other

in DSM- 5.9

7 Noth ing, however, prevents clinic ians who are comfortable conveying t heir diagnostic

impressions in the mult iaxial format from continu ing to use it.

8 America n Psychiatric Associ ation, Diagnosti c and Statistical Manu al of Mental Disorders,

5th ed (Washing ton DC: American Psych iatric Association, 2013) [DSM- 5].

9 DSM-5, ibid at 13.