Psychopathology and Classification

Sharon Eldar, Angelina F. Gómez, and Stefan G. Hofmann

Introduction

Psychopathology is a cognitive, emotional, behavioral or biological disorder within an

individual that is associated with distress or impairment in functioning, and is not typical
or culturally expected. A psychopathology, or mental disorder, is a multidimensional
construct that depends on the individual’s cultural and social context (Barlow, Durand,
& Hofmann, 2016). The aim of this chapter is to give an overview of mental disorders
as they are presently defined. We will first review the history of psychopathology, and
how its classification has changed over the years. We will also discuss the cultural
aspects involved in diagnosing psychopathology. Lastly, we will provide an overview of
the main psychological disorders and culturally relevant aspects of their classification.

History of Psychopathology

Many unusual and strange behaviors used to be viewed as expressions of supernatural

powers, such as evil spirits or the devil. This assumption caused people to turn to sor-
cery and violence to solve problematic behavior. In the fifteenth century the primary
explanation of psychopathology turned from supernaturalism to theories of the moon’s
influence on the mind, as well as the removal of the “soul” from the body. Gradually,
people began to agree on the existence of certain mental disorders, such as “hysteria.”
Unstable emotions began to be seen as consequences of these disorders, and systems of
classification of disorders started to emerge. For example, the Swiss-German philoso-
pher and physician, Paracelsus (1493–1541), is credited with starting the first

S. Eldar, Ph.D. • A.F. Gómez • S.G. Hofmann, Ph.D. (*)

Department of Psychological and Brain Sciences, Boston University,
648 Beacon Street, 6th Fl., Boston, MA 02215, USA
e-mail: [email protected]

© Springer International Publishing AG 2017 1

S.G. Hofmann (ed.), International Perspectives on Psychotherapy,
DOI 10.1007/978-3-319-56194-3_1
2 S. Eldar et al.

system of classification. He distinguished four key groups of mental/behavioral disor-

ders: Lunatici—reactions to phases of the moon; Insani—disorders present from birth
or inherited from family; Vesani—disorders originating from consumption of contami-
nated food or drink; and Melancholic—poor temperament and ability to reason. The
English scholar Robert Burton (1576–1640) extended this classification system, which
separated madness (mania) from melancholy (see Millon & Simonesen, 2010).
During the eighteenth and nineteenth centuries, as clinics and hospitals began
to record case histories and detailed observations of psychiatric patients, physi-
cians began to identify syndromal groupings (i.e., clusters of symptoms) and
classify them into disease entities. In addition, the growth of anatomical, physi-
ological, and biochemical bodies of knowledge, as well as the nineteenth-century
discoveries in bacterial and viral epidemiology, firmly established the disease
concept of modern medicine, including the view of mental illness as a disease
(Millon & Simonesen, 2010). As a result, thousands of people confined to dun-
geons of daily torture were released to asylums where medical forms of treat-
ment began to be investigated.
Around the turn of the twentieth century, two new sources of inspiration contributed
enormously to changes in the understanding and classification of psychopathology. The
first was the German physician Emil Kraepelin (1856–1926), who is considered the
founder of modern psychiatry. He hypothesized that specific symptom combinations
occurring throughout the course of a psychiatric illness allowed for the identification of
a particular mental disorder. He sought to bring order to symptom pictures and, most
importantly, to patterns of onset, course, and outcome. Another major influence was
Sigmund Freud (1856–1939). Freud’s psychoanalytic approach to psychopathology
was another major approach to understanding mental disorders. In contrast to Kraepelin’s
syndrome-based approach, Freud attempted to classify mental disorders based on etiol-
ogy and specifically emphasized a person’s early life experiences during childhood.
Psychopathology was seen as a product of dysfunctional personality dynamics that
evolving out of the manifold interactions between early life experiences, biological
endowment, and intrapsychic conflicts (for review see Blatt & Luyten, 2010; Mitchell &
Black, 2016). Psychoanalytic theory was the dominant approach to the classification and
treatment of mental illness throughout the latter half of the nineteenth century and begin-
ning of the twentieth century. Gradually, the new fields of behavioral and cognitive
psychology began to use empirical methods to explore psychopathological constructs
(as opposed to the case study approach favored by psychoanalytic or Neo-Freudian
theorists). This movement brought along new definitions of mental disorders, consider-
ing symptoms of mental disorders as reflecting underlying dimensions (e.g., neuroti-
cism), or discrete categories. However, regardless of whether mental disorders are
considered dimensional or categorical, both approaches assume that symptoms reflect
the presence of an underlying, unobserved, latent construct (e.g., Insel, 2014). This
notion is currently being reconsidered. An alternative to the latent disease model is the
complex network approach (Barabási, Gulbahce, & Loscalzo, 2011; Borsboom &
Cramer, 2013; Hofmann, Curtiss, & McNally, 2016). Instead of assuming that symptoms
arise from an underlying disease entity, this approach holds that disorders exist as sys-
tems of interrelated elements of a network. According to this view, emotional or b­ ehavioral
Psychopathology and Classification 3

problems do not reflect an underlying latent disease that causes their emergence and co-
occurrence. Instead, it is assumed that the network of the problems itself constitutes the
disorder, and it is the interaction between these problems that give rise and maintain the
disorder. For example, the complex network perspective does not assume that a stressful
event activates an underlying entity called depression, which then causes the emergence
of symptoms. Rather, it is assumed that stressful events activate certain problems (symp-
toms) that, in turn, activate other problems. Beyond studying the topography of a net-
work, this approach might also be used to predict therapy outcome, relapse, and recovering
by examining the network dynamics. Although highly promising, this approach will not
be discussed in greater detail. Instead, we refer the reader to Hofmann et al. (2016).

Assessment of Psychopathology

Since the inception of psychopathological classification in the sixteenth century,

different tools have been developed to determine whether a person’s symptoms
meet sufficient criteria to be characterized as a psychological disorder. Clinical
assessment refers to the systematic evaluation and measurement of psychological,
biological, and social factors in the individual. The process of clinical assessment
and diagnosis are central to the study of psychopathology and, ultimately, to the
treatment of psychological disorders.
The first systematic description of mental illness was not published until 1948,
when the World Health Organization (WHO) added a section about mental health to
its definition of health. Since then, many changes and developments have been
made in this domain. Currently, the two predominant international diagnostic sys-
tems are the Diagnostic and Statistical Manual of Mental Disorders (DSM), first
published in 1952 by the American Psychiatric Association (APA), and the WHO’s
chapter on mental disorders in the International Classification of Diseases and
Related Health Problems (ICD). Both systems employ a categorical approach to
classifying most psychiatric disorders, which ensures that researchers and clinicians
around the world can make reliable and valid diagnoses. These diagnostic texts
undergo revisions at irregular intervals, with the edition number appended to the
title; to date, the most recent versions are the DSM-5, published in 2013, and the
ICD-10, published in 1993.

The Diagnostic and Statistical Manual of Mental Disorders (DSM)

The publication of the first DSM (DSM-I) was motivated by increasing malcontent
with the unstandardized and unreliable methods of assessment and diagnosis
favored prior to the mid-twentieth century. Consequently, the APA formed the
Committee on Nomenclature and Statistics, which set out to classify mental ill-
nesses properly. The committee spit all psychiatric illnesses into three categories
4 S. Eldar et al.

based on the psychoanalytic approach: Psychoses, Neuroses, and Character disor-

ders. These categories were named but not described further, as the committee
believed vague definitions were more clinically useful (Blashfield, Flanagan, &
Raley, 2010). The DSM-II, published in 1968, added short descriptions of each
disorder, but still kept everything very vague. This version yielded low diagnostic
reliability, and was not used in countries other than the United States. The publica-
tion of the DSM-III in 1980 constituted a major change in the nosology of mental
disorders. Whereas the previous two versions were primarily psychoanalytic in
nature, this version attempted to take an atheoretical approach to classification in
order to be useful for clinicians with various theoretical viewpoints. Additionally,
disorder categories were more scientifically defined and structured, which increased
diagnostic reliability and validity. The DSM-III introduced the multiaxial system,
which included five levels of influence on an individual’s overall diagnostic picture:
characteristics of the clinical disorder itself (Axis I), personality style and/or mental
retardation (Axis II), relevant medical disorders (Axis III), environmental factors
(Axis IV), and overall functional impairment (Axis V). This framework allowed
clinicians to gather information about the individual’s functioning in a number of
areas, rather than limiting information to the disorder symptomatology. DSM-IV,
published in 1994, changed many disorder criteria, as well as added many new fea-
tures to each description, such as information related to race, gender, culture,
expanded description of diagnostic features, and information on differential diagno-
sis. This version barely depended on expert consensus, relying instead on literature
reviews and clinical trials to update and verify diagnostic criteria.
DSM-5. The most recent version of the DSM was the culmination of 14 years of
research, preparation, and revision (La Roche, Fuentes, & Hinton, 2015). These
revisions aimed to enhance clinical and research utility by providing concise diag-
nostic criteria for each disorder within a nosologically organized chapter frame-
work, as well as supplementing these descriptions with dimensional measures that
cross diagnostic boundaries, when appropriate. Additionally, this version includes a
brief digest of information about the diagnosis, risk factors, associated features,
research advances, and various expressions of the disorder (APA, 2013).
The most notable change in the DSM-5 was the removal of the multiaxial sys-
tem. Axis I was combined with Axis II and III, so along with the primary disorder
itself, clinicians can list as many medical conditions or personality disorder(s) as
necessary. Axis IV, which covered psychosocial and environmental contributions to
the disorder symptomology, was removed in order to better align with the ICD. The
global assessment of functioning (GAF) scale previously included in Axis V was
removed for reasons of insufficient conceptual clarity and clinical utility. In its
place, the second version of the WHO Disability Assessment Schedule (WHODAS
2.0) is included in section III of DSM-5 (APA, 2013).
The reason for these conceptual and structural changes was the recognition that
boundaries between disorders may be more porous than originally thought. Previous
versions of the DSM considered each disorder as categorically separate from other
diagnoses and health-related factors, and thus did not capture the widespread
commonalities in symptoms and risk factors across many disorders, as has
Psychopathology and Classification 5

been increasingly demonstrated in studies of comorbidity. Earlier editions of DSM

prioritized avoiding false-positives by making diagnostic categories very narrow
and specific, but critics argued that this approach did not fully capture the clinical
reality of symptom heterogeneity within disorders. As such, much of the debate sur-
rounding the development of the DSM-5 addressed this issue of categorical vs.
dimensional classification. Despite the strong proponents of moving to a dimen-
sional diagnostic system, the DSM-5 Task Force recognized that it is still premature
to completely redefine most disorders. Thus, the “hybrid” organizational structure
of the DSM-5 is meant to serve as a bridge to new diagnostic approaches without
causing unnecessary disruption of current clinical practice and research (Kupfer,
2013; Stein et al., 2010).
As part of its nosological reorganization, chapters in the DSM-5 are organized
based on developmental and lifespan considerations. The Manual begins with diag-
noses thought to reflect developmental processes manifested early in life (e.g., neu-
rodevelopmental disorders, schizophrenia and other psychotic disorders), followed
by diagnoses that more commonly onset in adolescence and young adulthood (e.g.
bipolar, depressive, and anxiety disorders), and ends with diagnoses relevant to
adulthood and later life (e.g., neurocognitive disorders). A similar approach is taken
within each chapter, where possible. This organizational structure facilitates the
comprehensive use of lifespan information as a way to assist in diagnostic decision-­
making. In addition to these changes, the DSM-5 included significant content revi-
sions to the diagnostic criteria of many disorders; these changes range from
relatively minor alterations, such as new time-duration or symptom-count require-
ments, to major redefinitions, such as the dimensional assessment of Alcohol Use
Disorders and Autism Spectrum Disorders. For more details on the changes from
DSM-IV-TR to DSM-5 see: ­http://www.dsm5.org/documents/changes%20
from%20dsm-iv-tr%20to%20dsm-5.pdf.

I nternational Classification of Diseases and Related Health

Problems (ICD)

The history of psychiatric classification in the ICD contains many similarities to the
developments seen in the DSM. The sixth edition of the ICD, published in 1948,
was the first to include a description of mental health disorders. Nevertheless, it was
not until the early 1960s that the Mental Health Program of the WHO became
actively engaged in improving the diagnosis and classification of mental disorders.
At that time, the WHO convened a series of meetings that actively involved experts
from different psychiatric disciplines and schools of thought, and well as represen-
tatives from all parts of the world. This extensive consultation process yielded
numerous proposals to improve the classification of mental disorders, many of
which were used in drafting the eighth edition of the ICD. However, much like the
DSM-II, this edition had little international influence due to its severe lack of diag-
nostic reliability.
6 S. Eldar et al.

The 1970s brought further interest in improving psychiatric classification world-

wide. This growth was due to the expansion of international collaborative studies,
the availability of new treatments, and the need to develop specific criteria for clas-
sification in order to improve diagnostic reliability. Drawing from empirical support
provided by international research collaborations and scientific conferences, the
ICD-10 contains a clear set of diagnostic criteria, as well as assessment instruments
to reliably obtain these diagnoses.
The tenth edition (ICD-10, 1993) chapter on mental health was developed simul-
taneously to the DSM-IV, to make them as compatible as possible. Accordingly, this
version classifies mental disorders using a criteria-based system, and also includes
detailed descriptions of the symptomology and clinical picture. There are, however,
still differences between the two manuals in a few key areas. First, certain defini-
tions or descriptions differ slightly; for example, Schizophrenia and Schizoaffective
Psychoses have different criteria, and a traumatic event is defined differently within
the Trauma-related disorders. Second, some disorders in the DSM are completely
absent from the ICD, such as Narcissistic Personality Disorder, or Bipolar II.
Another key distinction is the ICD-10 maintains a multiaxial system, similar to
DSM-IV with which it was developed. This system allows for social/environmental,
functional impairment, and somatic factors to be considered in tandem with the
psychiatric criteria. Lastly, the ICD not only contains descriptions of mental disor-
ders, but also all medical disorders or causes of death; due to this vast scope, each
version of the ICD comprises several distinct editions. The edition with the classifi-
cation of mental disorders is in the ICD-10, but was published in 1992 and is there-
fore rather behind the DSM in terms of recent updates. The ICD-11 editing and
development process began in 2007, and is projected to finish in 2018. As in the
previous edition, ICD-11 was developed concurrently with the DSM-5. In both new
editions, the grouping of disorders was changed from being based primarily on
common presenting symptoms, to an organizational system that reflects common
underlying etiological factors (where possible). The current status of the ICD-11
can be viewed online at: http://apps.who.int/classifications/icd11/browse/l-m/en.

Culture and Psychopathology

The study of psychopathology has traditionally been a Western pursuit emphasizing an

individual-centered medical model. This system is consistent with an emic approach,
or research conducted from the perspective of the subject, though there has been
increasing interest in employing an etic approach, or research from the perspective of
an outside observer. In this approach, researchers attempt to identify the universal ele-
ments of psychopathology, whereas research from an emic perspective studies specific
psychopathologies within a given culture. In each of these approaches, “culture” has
often been poorly or inconsistently defined. It is insufficient to define culture solely
through proxy and broadly defined variables such as skin color (i.e., race) or place of
birth (i.e., ethnicity). It is necessary to take into account the ways in which people
Psychopathology and Classification 7

construct different cultural meanings, which are a result of a multiplicity of causes

including religion, socioeconomic factors, and so forth. Culture refers to systems of
knowledge, concepts, rules, and practices that are learned and transmitted across gen-
erations. This includes language, religion and spirituality, family structures, life-cycle
stages, ceremonial rituals, and customs, as well as moral and legal systems (Schwartz,
Unger, Zamboanga, & Szapocznik, 2010).
Prior to the DSM-5, critics using a cultural framework (e.g., La Roche, 2013;
Sue & Sue, 2008) argued that the DSM’s nosological system is based on Western
American beliefs (e.g., individualism, emphasis on biology) and practices (e.g.,
standardization), which limits the system’s usefulness among different cultural
groups. More specifically, when Western American standards are used to diagnose
cultural minorities it is more likely that culturally based factors will be miscon-
strued or overlooked (Hinton & Good, 2009; La Roche, 2013). This insufficient
attention to cultural aspects is primarily a function of the DSM’s emphasis on stan-
dard diagnostic criteria that can clearly define homogenous mental disorders. In
addition, cultural differences and influences on psychopathology can be hard to
articulate, and are even considered by some to be “superficial” characteristics next
to biological considerations of disease etiology and maintenance. Moreover,
research on cultural topics is not typically prioritized among American researchers,
and is usually published in small journals—though this trend is slowly changing as
research pursuits become increasingly global.
A cultural perspective on the study of psychopathology is important for several
reasons. First, it may help in the development of culture-specific therapies. Second,
it may provide valuable information about the psychological problems seen in par-
ticular cultures and their development as a function of the particular demands that
culture places on individuals. Third, the examination of culture-specific syndromes,
which are interesting in and of themselves, may help illuminate more general
­patterns of cultural values as they relate to the classification of mental disorders.
Lastly, and most importantly, understanding the cultural context of mental disorders
is essential for effective diagnostic assessment, clinical management, and treatment.
Mental disorders should be defined in relation to cultural, social, and familial norms
or values, particularly when defining “clinically significant impairment,” as this
subjective criterion can be heavily influenced by cultural norms. Culture provides
an interpretive framework that shapes the experience and expression of the symp-
toms, signs, and behaviors that make up diagnostic criteria. Although some forms of
psychopathological expression can be universal, cultural aspects can affect the man-
ifestation of certain symptoms, and consequently the prevalence of mental disorders
(Alegria et al., 2004). The boundaries between normality and pathology vary across
cultures for specific types of behaviors. Thresholds of tolerance for specific symp-
toms or behaviors differ across cultures, social settings, and families. Hence, the
level at which an experience becomes problematic or pathological will differ (APA,
2013). For example, all human beings will likely experience low moods, but cultural
factors are important in defining what is considered “low,” what terms are used to
express these moods, when and how they are recognized as pathological, and how
or from whom help is sought (Bhugra, 2009).
8 S. Eldar et al.

Diagnostic assessment must therefore consider whether an individual’s experi-

ences, symptoms, and behaviors differ from sociocultural norms and lead to difficul-
ties in adaptation in the cultures of origin and in specific social or familial contexts.
Accordingly, key cultural aspects relevant to diagnostic classification and assessment
were considered in the development of the DSM-5. These considerations prompted
the inclusion of a new “glossary of cultural concepts of distress,” which describe
several culture-specific syndromes, such as: Ataque de nervios (an emotional upset,
including anxiety, anger, or grief among Latinos), Dhat syndrome (South Asian cul-
tural explanation for semen loss in young men), or Taijin kyofusho (Japanese anxiety
and avoidance of social interactions because of a fear of acting inadequate or offen-
sive to others). Furthermore, the DSM-5 presents a Cultural Formulation Interview
(CFI) in its appendices. This 16-item semi-structured interview is an assessment tool
aimed at more accurately identifying components of an individual’s cultural back-
ground that might impact their clinical presentation and care. The CFI directly assess
an individual’s beliefs, as well as define idioms of distress, rather than simply catego-
rizing individuals as “multicultural” based on their skin color or place of birth. The
information provided throughout the CFI can help practitioners avoid misdiagnosis,
obtain clinically useful information, improve clinical rapport and therapeutic effi-
cacy, guide research, and clarify cultural epidemiology.

Overview of Psychopathologies

In the next sections we will briefly describe a number of psychopathological catego-

ries and disorders contained in the DSM-5 and ICD-10. We will limit our discussion
to some of the most common disorders.

Mood Disorders

Mood disorders describe a serious disturbance in mood, and are usually divided into
depressive disorders and bipolar-related disorders. The ICD-10 groups these disor-
ders under the same category, but the DSM-5 separated them, placing the bipolar-­
related disorders after the psychotic disorders chapter, and before the depressive
disorders chapter. This change was the result of increasing evidence suggesting that
bipolar disorders are etiologically similar to both diagnostic classes in terms of
symptomatology, family history, and genetics (APA, 2013).
Depression is one of the most common mental disorders. The World Health
Organization (WHO, 2016) estimated that depression affects 350 million people in
the world. It is the leading cause of disability in the U.S and the world for people
between ages 15 and 44, and 80% of people with depression are limited in their
daily functioning, particular at work. The depressive disorders include Major
Depressive Disorder (MDD), Persistent Depressive Disorder (previously d­ ysthymia),
Psychopathology and Classification 9

and Disruptive Mood Dysregulation Disorder (DMDD). The common feature of all
depressive disorders is the presence of sad, empty, or irritable mood, accompanied
by somatic and cognitive changes that significantly affect the individual’s capacity
to function. People with depression may experience a lack of interest and pleasure
in daily activities, significant weight loss or gain, insomnia or excessive sleeping,
lack of energy, inability to concentrate, feelings of worthlessness or excessive guilt
and recurrent thoughts of death or suicide. The depressive disorders are differenti-
ated by their symptom course, age of onset, or presumed etiology (APA, 2013;
Leahy, Holland, & McGinn, 2012).
Bipolar related disorders are a cluster of disorders in which common emotions
become magnified in intense and often unpredictable ways. Individuals with bipolar
disorder can quickly swing from extremes of happiness, energy and clarity to sad-
ness, fatigue and confusion. These shifts can be so devastating that individuals may
choose suicide. The diagnosis of a bipolar disorder requires the experience of at
least one manic episode, which describes a period of abnormally elevated or irrita-
ble mood resulting in over-activity, pressured speech, and decreased need for sleep.
Bipolar disorders can also include episodes of depression, though not all people
with mania become depressed. The ICD-10 also includes a diagnosis of Hypomania,
which includes the same symptoms as a manic episode with two important differ-
ences: the mood disturbance is not severe enough to cause hospitalization or great
functional impairment, and the episode does not include psychotic features. Bipolar
disorders, in their various forms, affect 3.4% of the world’s population, but the
prevalence differs by country. For example, Merikangas et al. (2011) found that the
United States has the highest lifetime and 12-month prevalence of bipolar disorders
(4.4% and 2.8%, respectively), while India has the lowest (both 0.1%).
These cultural differences are also manifested in the variety of symptoms related to
depression and bipolar disorders. For example, while depression has a core set of
symptoms, (including low mood, sleep problems, lack of interest and energy, and poor
concentration), other symptoms, such as shame and guilt, psychomotor retardation,
low self-esteem and low self-confidence are more likely to vary across cultures.
Similarly, in hypomania, over activity, sexual disinhibition and irritability are most
likely universal, but behaviors such as over-spending may differ across ethnic and
cultural groups (Bhugra, 2009). The main mood disorders are described in Table 1.

Anxiety Disorders

Anxiety Disorders are characterized by excessive worry about some feared out-
come, which is disproportionate with the actual risk of that outcome, persists past
the point where such anxious attention might be adaptive, and causes clinically
significant distress, functional impairment, or avoidance. Within the anxiety disor-
ders fall more specific diagnoses, including general anxiety, social anxiety, and
panic disorder. The core feature of all anxiety disorders is worry, but the object of
worry and the typical behavioral response patterns differ slightly for each disorder.
10 S. Eldar et al.

Table 1 Description of mood disorders

Disorder Description
Major depression Sad mood or loss of interest or pleasure, accompanied by other symptoms
disorder (MDD) such as sleep problems, weight loss/gain, psychomotor agitation/
retardation, and lack of energy; symptoms are present for most of the day,
nearly every day, for at least 2 weeks
Persistent Depressed mood that occurs more days than not for most of the day,
depressive disorder lasting for at least 2 years. This mood is accompanied by other symptoms
(dysthymia) described in MDD
Disruptive mood Presentation of children (up to 12 years of age) with persistent irritability
dysregulation and frequent episodes of uncontrolled extreme behavior and
disorder temperamental outbursts
Bipolar I At least one full manic episode; the occurrence of a major depressive
episode may follow, but is not required for a diagnosis
Bipolar II A hypomanic episode diagnosed after one or more major depressive
episode
Cyclothymia A chronic (at least 2 years) fluctuating mood disturbance, involving
numerous distinct periods of hypomania and depression

Anxiety disorders are some of the most prevalent disorders, affecting three out of
ten people in their lifetime (Kessler et al., 2005). They tend to be chronic, start early
in life (Martin, 2003), and comorbid with other mental illnesses (Michael, Zetsche,
& Margraf, 2007). The most common anxiety disorders are described below, and
brief descriptions of all anxiety disorders can be found in Table 2.
As far as research has explored, general anxiety disorder appears in most cul-
tures; however, there is a great degree of variation in the expression of anxiety
between cultures. More specifically, anxiety is manifested in primarily somatic
symptoms in some cultures, but takes a more cognitive focus among others.
Additionally, the content and severity of worry tends to be culture-specific, so a
diagnosis of general anxiety disorder must be made within the context of what the
individual’s society views to be worrisome and excessive (Marques, Robinaugh,
LeBlanc, & Hinton, 2011).
Generalized Anxiety Disorder (GAD) describes a pattern of excessive worry that
occurs most days for at least 6 months; this worry is hard to control, causes clinically
significant distress or functional impairment, and is associated with three or more
psychosomatic symptoms of distress, including: restlessness, fatigue, difficulty con-
centrating, irritability, muscle tension, or sleep disturbance (APA, 2013). Whereas
normative anxiety waxes and wanes, general anxiety disorder tends to persist through-
out a person’s life, and rates of full remission are very low (Rodriguez et al., 2006).
The 12-month prevalence of general anxiety disorder is estimated around 18% of the
world’s adult population (Kessler, Chiu, Demler, & Walters, 2005). Generalized anxi-
ety disorder is present in both males and females, though the disorder is much more
common among females (Yonkers, Warshaw, Massion, & Keller, 1996).
Social anxiety disorder (SAD, formerly social phobia). In SAD the content of the
worry is specific to social situations in which the individual is potentially exposed
to scrutiny or negative evaluation. These situations could include real evaluative
Psychopathology and Classification 11

Table 2 Description of anxiety disorders

Disorder Description
Separation anxiety Developmentally inappropriate and excessive anxiety surrounding
disorder separation from attachment figures, lasting at least 4 weeks in
children, or 6 months in adults
Selective mutism Consistent failure to speak in specific social situations, despite
speaking in other situations; disturbance lasts at least 1 month and
interferes with education or occupational achievement, or social
communication
Specific phobia Marked fear of a specific object or situation (e.g. flying, heights,
animals, injections), which is disproportionate to the actual threat of
harm, causes functional impairment or distress, and lasts for at least
6 months
Social anxiety disorder Excessive worry about negative evaluation in social situations, lasting
(SAD, formerly social for at least 6 months and causing significant distress, impairment, or
phobia) avoidance behaviors
Panic disorder Experience of at least one panic attack, followed by at least 1 month
of excessive worry about having another panic attack, or intolerance
of panic symptoms
Agoraphobia Fear of being public places from which escape might be difficult;
fears and behavioral avoidance last at least 6 months and cause
significant distress or impairment
General anxiety Excessive and pervasive worry about issues of daily life, associated
disorder (GAD) with persistent psychosomatic symptoms of worry; symptoms last for
at least 6 months, and cause clinically significant distress, avoidance
behaviors, and/or functional impairment

circumstances, such as giving a presentation or going on a date, but could also be

casual social settings such as going to dinner with friends. Regardless of the circum-
stance, the individual with social anxiety experiences a degree of fear that is dispro-
portionate to the actual risk of being negatively evaluated or the consequences of
such an evaluation; this fear is frequently so intense that the person will completely
avoid the situation, or will endure it with debilitating anxiety. Social anxiety disor-
der tends to onset earlier in life; 50% of cases onset by 11 years of age, and 80% by
the age of 20 (Stein & Stein, 2008). Community estimates of rates of remission vary
widely, but the average remission rate based on prospective studies is estimated to
be around 50% (Vriends, Bolt, & Kunz, 2014).
In East Asian cultures such as Japan and Korea, the syndrome of taijin kyofusho
is very similar to social anxiety disorder, as it is characterized by a fear of social
evaluation associated with the concern that the individual makes other people
uncomfortable (Kleinknecht, Dinnel, Kleinknecht, Hiruma, & Harada, 1997).
Additionally, the prevalence of social anxiety disorder may not accurately reflect the
prevalence of social anxiety symptoms; for example, Asian cultures typically have
the lowest rates of the disorder, but individuals in these cultures still clearly experi-
ence symptoms of social anxiety. This discrepancy perhaps reflects different per-
ceptions of what constitutes “excessive” or “pathological” social anxiety, and thus
12 S. Eldar et al.

it is essential to consider an individual’s cultural context when making a diagnosis

(Hofmann, Asnaani, & Hinton, 2010).
Panic Disorder. Panic Disorder differs from general and social anxiety disorder
inasmuch as the primary object of anxiety is the experience of anxiety itself; more
specifically, individuals with panic disorder have experienced at least one panic
attack, which then leads to excessive worry about having another panic attack, or
the consequences of such panic symptoms (e.g. worry about being “crazy” or hav-
ing a stroke). Additionally, this subsequent concern can be manifested in significant
and maladaptive behavioral changes related to the fear of having an attack, such as
avoidance of unfamiliar situations or cardiovascular exercise.

Obsessive-Compulsive Spectrum Disorders

In previous versions of the DSM, OCD was classified under the Anxiety Disorders.
However, the DSM-5 created a new chapter on Obsessive Compulsive and Related
Disorders, which in addition to OCD includes body dysmorphic disorder (BDD),
hoarding disorder, trichotillomania (hair-pulling disorder), and excoriation (skin-­
picking) disorder (Stein, Craske, Friedman, & Phillips, 2014). The inclusion of this
new chapter reflects the gathering empirical evidence that these disorders share
diagnostic characteristics, as well as etiological pathways (Monzani, Rijsdijk,
Harris, & Mataix-Cols, 2014). All of the obsessive-compulsive spectrum disorders
are characterized by preoccupations, repetitive behaviors or mental acts in response
to those preoccupations, the excessive or developmentally atypical persistence of
symptoms, and clinically significant functional impairment or distress (APA, 2013).
The following includes a description of OCD, and a brief review of the OC spec-
trum disorders is presented in Table 3.
Obsessive compulsive disorder (OCD) is a debilitating psychiatric disorder con-
sisting of persistent intrusive thoughts or images, and/or compulsory behaviors that
cause significant distress and anxiety. OCD affects approximately 2% of the popula-
tion, and commonly emerges in childhood and adolescence. As a clinically heteroge-
neous disorder, individuals with OCD may present with a variety of symptom
profiles. Obsessions are recurrent thoughts, urges, or images that are unwanted, yet
repetitively intrude into an individual’s mind and cause anxiety and distress. The
individual will often ignore or suppress these obsessions, or will attempt to neutralize
them with another thought or action. Such a neutralizing thought or action is consid-
ered a compulsion, defined as any behavior or mental act that the individual feels
driven to perform in order to prevent or reduce anxiety or distress associated with an
obsession (e.g. cleaning, arranging, checking, or praying). While repetitive or ritual-
ized behaviors are common among the general population and can even be quite
useful (e.g. organizational aids or personal hygiene rituals), the symptoms of OCD
are much more extreme, and cause varying degrees of impairment across any or all
domains of life, including personal, social, occupational, and even medical health.
Psychopathology and Classification 13

Table 3 Description of obsessive-compulsive spectrum disorders

Disorder Description
Obsessive-compulsive Presence of obsessions, compulsions, or both, which occupy at least
disorder (OCD) 1 h/day or cause significant distress or impairment
Body dysmorphic Preoccupation with one or more perceived defects or flaws in physical
disorder (BDD) appearance, associated with repetitive behaviors or mental acts, and
which cause distress or impairment
Hoarding disorder Persistent difficulty discarding possessions, regardless of their actual
(HD) value, which results in compromised living areas and causes distress or
impairment
Trichotillomania Recurrent hair-pulling resulting in hair loss and significant distress or
(hair-pulling disorder) impairment
Excoriation (skin-­ Recurrent skin-picking resulting in skin lesions and significant distress
picking) disorder or impairment

Obsessions and compulsions can also be time-consuming, and even if an individual

reports no distress or impairment, a diagnosis of OCD may still be given if the symp-
toms occupy more than an hour each day (Gómez, Cooperman, & Geller, 2015).

 rauma and Stressor Related Disorders (Including Dissociative

T
Disorder)

Similar to the obsessive-compulsive disorders chapter, the chapter on trauma- and

stressor-related disorders is new to the DSM-5. This chapter includes disorders in
which exposure to a traumatic or stressful event is listed explicitly as a diagnostic
criterion. In DSM-IV, post-traumatic stress disorder (PTSD) and acute stress disor-
der were under the umbrella of anxiety disorders, but a distinct chapter was war-
ranted for a few reasons. First, trauma-related disorders differ from anxiety disorders
in the variety of commonly elicited emotions (e.g. guilt, rage and shame, not only
anxiety and fear-based symptoms); second, they all share a proximal instigating
stressful event followed by intense emotional responses, whereas anxiety disorders
are not typically caused by one triggering event; lastly, the ICD-10 has long distin-
guished trauma-related disorders from anxiety disorders (Möller et al., 2015). The
trauma and stressor-related disorders include PTSD, acute stress disorder, reactive
attachment disorder, disinhibited social engagement disorder, and adjustment disor-
ders, each of which will be briefly described.
PTSD is a well-recognized psychiatric disorder that occurs following a major trau-
matic event. The event must be an exposure or repeated exposures to actual or threat-
ened death, serious injury, or sexual violence, which the individual experienced or
witnessed while it was happening. A diagnosis of PTSD may also be given if the person
learned about (but did not witness) an event that happened to a close relative, but only
if the event was violent or accidental. The characteristic symptoms of PTSD include
re-experiencing phenomena (such as nightmares or recurrent distressing thoughts or
14 S. Eldar et al.

intrusive images of the event), avoidance and numbing of general responsiveness (such
as trying not to talk about or be reminded of the traumatic event), feelings of detach-
ment or estrangement from other people, and symptoms of hyperarousal, including
sleep disturbance, increased irritability and hypervigilance (Bisson & Andrew, 2007).
In order to be diagnosed with PTSD all of these symptoms need to be present for more
than a month.
PTSD is more prevalent among females than among males across the lifespan,
and lifetime risk for PTSD using DSM-IV criteria is 8.7% (Kessler, Berglund, et al.,
2005). The risk of onset and severity of PTSD may differ across cultural groups as
a result of variation in the type of traumatic exposure. The diagnostic criteria for
PTSD are valid cross-culturally, in that they constitute a cohering group of symp-
toms that occur in diverse cultural settings in response to trauma. However, there are
some differences in symptoms expression across cultural, such as the salience of
avoidance and somatic symptoms, and the importance of distressing dreams (Hinton
& Lewis-Fernandez, 2011).
Acute stress disorder has a similar symptom profile as PTSD, but a shorter time-­
requirement, as symptoms can last for 3 days to 1 month following exposure to one
or more traumatic events (Bryant, Friedman, Spiegel, Ursano, & Strain, 2011).
Similarly, a diagnosis of adjustment disorder applies to milder reactions to a stress-
ful life event, which nevertheless cause significant distress and impairment at least
3 months following the stressor. The ICD-10 emphasizes that the adjustment disor-
der diagnosis should be given following a stressor that is not unusual or catastrophic,
such as a move or transition to a new job.
Dissociative disorders. These disorders are also part of the trauma- and stressor-­
related category in the ICD-10, although they have their own category in the DSM-­
5. Dissociative disorders are characterized by a disruption of and/or discontinuity in
the normal integration of consciousness, memory, identity, emotion, perception,
body representation, motor control, and behavior. The dissociative disorders are
frequently found in the aftermath of trauma, and many of the symptoms are influ-
enced by the proximity to trauma (Wolf et al., 2012).
There are a few stress-related disorders that typically occur in childhood; the
DSM-5 places these disorders in the stressor-related chapter, whereas the ICD-10
classifies these disorders under the age-related or developmental disorders category.
Reactive attachment disorder is defined as a pattern of markedly disturbed and
developmentally inappropriate attachment behaviors in response to early childhood
stressors or severe neglect. Developmentally inappropriate attachment behaviors
include rarely or minimally turning to an attachment figure (i.e. parent or primary
caregiver) for comfort, support, protection, and nurturance (Zeanah, Chesher, &
Boris, 2016). Disinhibited social engagement disorder is a pattern of behavior in
which the child shows no inhibitions when approaching adults, and this overly
familiar behavior violates the social boundaries of the culture. In order to get the
diagnosis, the child must be at least 9 months old, the age at which they are devel-
opmentally able to form selective attachments (Lehmann, Breivik, Heiervang,
Havik, & Havik, 2016).
Psychopathology and Classification 15

Substance-Related and Addictive Disorder

The substance-related disorders encompass eight to ten separate classes of drugs:

alcohol; caffeine; cannabis; hallucinogens (with separate categories for phencycli-
dine and other hallucinogens); inhalants; opioids; sedatives, hypnotics, and anxio-
lytics; stimulants (amphetamine-type substances, cocaine, and other stimulants);
tobacco; and other (or unknown) substances. The pharmacological mechanisms by
which each class of drugs activates reward systems in the brain are different, but all
produce feelings of pleasure (Volkow, Koob, & McLellan, 2016). In addition to the
substance-related disorders, this category of disorders also includes gambling disor-
der, reflecting evidence that gambling behaviors activate reward systems similar to
those activated by drugs of abuse, as well as produce some behavioral symptoms
that appear comparable to those produced by the substance use disorders
(Romanczuk-Seiferth, van den Brink, & Goudriaan, 2014).
Across the substance classes, the DSM-5 classifies two types of disorders, and the
ICD-10 also includes similar classifications, but in a slightly different format. One is
the Substance-Use Disorder (DSM-5) or Dependence Syndrome (ICD-10). This
disorder-type refers to a problematic pattern of use, which leads to clinically signifi-
cant impairment or distress. Unlike many other disorders, this “functional impair-
ment” criterion contains more specific descriptions of possible manifestations. For
example, consumption of a larger amount of the substance over a longer period than
was originally intended; a persistent desire or unsuccessful efforts to control or curb
use; marked craving for the substance; continued use despite social or interpersonal
problems as a result of substance-use, etc. The DSM-5 includes a list of 11 symp-
toms, and the number of symptoms endorsed by the individual defines the severity of
the disorder. Critics of this approach claim that the individual’s history of use and
other emotional experiences may be more informative and predictive of future
impairment than simply counting symptoms (Lima et al., 2015). The fact that the
ICD-10 includes fewer symptoms than the DSM-5 reinforces this critique, and cre-
ates differences between the two diagnostic systems (Möller et al., 2015).
The second disorder-type in the substance use category is the induced disorders,
which include intoxication, withdrawal, and other substance/medication-induced
mental disorders (e.g., substance-induced psychotic disorder, substance-induced
depressive disorder). Intoxication disorders (e.g. opioid intoxication; sedative, hyp-
notic or anxiolytic intoxication) are clinically significant problematic behavioral or
psychological changes that developed during, or shortly after, the use of a sub-
stance. For a person to become intoxicated depends on which drug is taken, how
much is ingested, and the person’s individual biological reaction. Symptoms of
intoxication differ across substance classes, and usually include impaired judgment,
mood changes, and lowered motor ability. Withdrawal disorders (e.g. stimulant
withdrawal; caffeine withdrawal) are characterized by physiological and psycho-
logical symptoms, such as changes in mood, sleep, and appetite dysregulation,
which develop shortly after cessation or reduction of substance consumption, and
which cause significant distress or impairment (Starcevic, 2016).
16 S. Eldar et al.

Somatic Disorders

Somatic disorders are broadly characterized by anxiety or distress related to the

experience of physical symptoms such as pain or fatigue (Dimsdale et al., 2013).
This category includes two main disorder-types, which have different names and
slightly different criteria in the DSM and the ICD. The first disorder-type includes
Somatic Symptom Disorder (DSM-5), or Somatization Disorder (ICD-10), which
describe psychological distress that is associated with, and compounds the severity
of, physical symptoms such as pain; the other disorder-type includes Illness Anxiety
(DSM-5), or Hypochondriacal Disorder (ICD-10), which describe a persistent pre-
occupation and anxiety that is focused on the possibility of having or developing a
serious disease.
Somatic disorders are among the most frequent reasons for doctor visits, and are
present in 10–20% of primary care patients (Sharma & Manjula, 2013). Consequently,
somatic disorders are associated with public health costs that are comparable to
those caused by anxiety and depressive disorders (Konnopka et al., 2012; Kroenke,
2007; Steinbrecher, Koerber, Frieser, & Hiller, 2011). Additionally, the functional
impairment associated with somatoform disorders is comparable to that seen in
depressive and anxiety disorders. Somatic disorders may also accompany other psy-
chiatric disorders, especially depression and anxiety, and the complexity introduced
by this dual diagnosis often results in higher severity, functional impairment, and
even refractoriness to traditional anxiety or depression treatments (Katz,
Rosenbloom, & Fashler, 2015).
The DSM-5 and the ICD-10 define somatic disorders differently, but a common
feature is the association between physiological symptoms and significant distress
or impairment. The main difference lies in how each set of diagnostic criteria handle
the occurrence of true somatic symptoms. In the ICD-10 (as well as in the DSM-IV),
diagnostic criteria specify that the individual’s physical symptoms cannot be
explained by any detectable physical condition. However, in the DSM-5 a diagnosis
is made on the basis of distressing somatic symptoms plus abnormal thoughts, feel-
ings, and behaviors in response to these symptoms, rather than the absence of a
medical explanation for somatic symptoms. The notion behind this change is that
incorporating affective, cognitive, and behavioral components into the criteria pro-
vides a more comprehensive and accurate reflection of the true clinical picture than
can be achieved by assessing the somatic complaints alone (APA, 2013).
Research on cultural factors involved in somatic disorders indicates that somati-
zation—in all of its various definitions—is common among all cultural groups and
societies. Differences among groups may reflect cultural styles of expressing dis-
tress that are influenced not only by cultural beliefs and practices, but also by famil-
iarity with health care systems and pathways to care (Kirmayer & Young, 1998).
Psychopathology and Classification 17

Feeding and Eating Disorders

Feeding and eating disorders are characterized by a persistent disturbance of eating or

eating-related behavior that results in the altered consumption or absorption of food, and
which significantly impairs physical health or psychosocial functioning (APA, 2013).
Feeding and eating disorders are associated with increased psychopathology, health
problems, and impairment in quality of life (Hilbert, de Zwaan, & Braehler, 2012).
Diagnostic criteria are provided for pica, rumination disorder, avoidant/restric-
tive food intake disorder, anorexia nervosa, bulimia nervosa, and binge-eating dis-
order, and are presented in Table 4. The more prevalent disorders are anorexia
nervosa (0.3%), bulimia nervosa (0.9%), and binge-eating disorder (1.6%)
(Swanson, Crow, Le Grange, Swendsen, & Merikangas, 2011). Eating disorders are
rare in the general population, but are more common among adolescent girls and
young women; nevertheless, they can affect both women and men of different ages
and baseline weights (Hilbert et al., 2012; Hoek & van Hoeken, 2003).
Between 1960 and 2000, the frequency of eating disorders increased dramati-
cally among Western countries, which emphasizes the strong influence of cultural
factors on the development and maintenance of eating disorders (Lindvall Dahlgren
& Wisting, 2016). To this day, the etiology of eating disorders seems to be more
sociocultural than psychological or biological, as is the case for other disorders.
This understanding is based on the low incidence of eating disorders among coun-
tries and cultures in which people are struggling to buy and find food. However, this
pattern may be shifting, as there is evidence that eating disorders are emerging in
Eastern cultures as well (Barlow et al., 2016).

Sleep-Wake Disorders

Sleep is essential for a person’s health and wellbeing, though the amount sleep
needed varies among individuals (Flueckiger, Lieb, Meyer, Witthauer, & Mata,
2016). In general, most healthy adults are built for 16 h of wakefulness and need an
average of 8 h of sleep a night. Unfortunately, up to 60% of adults report experienc-
ing sleep problems at least a few nights a week, due to different stressors, living and
working style, and physiological conditions. The majority of individuals with these
sleep problems go undiagnosed and untreated (Demir et al., 2015). In addition,
more than 40% of adults experience daytime sleepiness severe enough to interfere
with their daily activities at least a few days each month, with 20% reporting impair-
ing sleepiness a few days a week or more. Groups that are particularly at risk for
sleep deprivation include night shift workers, physicians, truck drivers, parents, and
teenagers (APA, http://www.apa.org/topics/sleep/why.aspx). The prevalence of
sleep-wake disorders depends on the type of disorder, and ranges from rare (e.g.
narcolepsy, <1% of the population), to common (e.g. insomnia, 6–10%; breathing–
related sleep disorders, 2–15%; rapid eye movement sleep behavior disorder,
10–30%) (Chung et al., 2015).
18 S. Eldar et al.

Table 4 Description of eating disorders

Disorder Description
Pica Persistent eating of nonnutritive, nonfood substances over a
period of at least 1 month. The eating is inappropriate to the
developmental level of the individual, and is not part of a
culturally supported or socially normative practice
Rumination disorder Repeated regurgitation of food over a period of at least 1
month. Regurgitated food may be re-chewed, re-swallowed, or
spit out, and is not attributable to an associated gastrointestinal
or other medical condition
Avoidant/restrictive food Avoidance or restriction of food intake, manifested by
intake disorder clinically significant failure to meet requirements for nutrition
or insufficient energy intake through oral intake of food
Anorexia nervosa An intense fear of gaining weight or of becoming fat,
accompanied with significantly distorted body image. The
individual maintains a body weight that is below a minimally
normal level, but is nevertheless afraid of being fat. Gaining
weight, or even failure to continually lose weight, can cause
intense panic, anxiety and depression. Death most commonly
results from medical complications associated with the
disorder itself or from suicide
Bulimia nervosa Recurrent episodes of binge eating and compensatory behavior,
such as self-induced vomiting, strict dieting, or the misuse of
laxatives. Binge-purge episodes must occur at least once per
week for 3 months. Regular purging can be very destructive
physiologically, and has the potential to cause permanent
damage to functions, including endocrine, cardiovascular, and
dental health. Individuals are typically ashamed of their eating
problems and attempt to conceal their symptoms
Binge-eating disorder (BED) Recurrent episodes of uncontrolled binge eating that must
occur, on average, at least once per week for 3 months. Unlike
bulimia nervosa, BED does not include compensatory purging
behavior. Binge eating must be characterized by marked
distress and at least three of the following features: Eating
much more rapidly than normal; eating until feeling
uncomfortably full; eating large amounts of food when not
feeling physically hungry; eating alone because of feeling
embarrassed by how much one is eating; and feeling disgusted
with oneself, depressed, or very guilty afterward

Sleep-wake disorders encompass a broad range of clinical features. They are

traditionally divided into two large categories: Dyssomnias and Parasomnias
(Ohayon, 2005). Dyssomnias are sleep disorders characterized by abnormalities in
the amount, quantity, or timing of sleep. As such, they are associated with difficulty
initiating or maintaining sleep, as well as daytime sleepiness (Chung et al., 2015).
This category includes insomnia disorder, hypersomnolence disorder, narcolepsy,
breathing-related sleep disorders, and circadian rhythm sleep-wake disorders.
Parasomnias cover abnormal behavioral or physiological events occurring during
sleep, but not involving the sleep mechanisms per se. Under this category are the
Psychopathology and Classification 19

non-rapid eye movement (NREM) sleep arousal disorders, nightmare disorder,

rapid eye movement (REM) sleep behavior disorder, restless legs syndrome, and
substance/medication-induced sleep disorder. Individuals with these disorders usu-
ally complain about daytime distress and impairment, depression, anxiety, and cog-
nitive changes. Furthermore, persistent sleep disturbances (both insomnia and
excessive sleepiness) are established risk factors for the subsequent development of
mental illness and substance use disorders (APA, 2013). A summary of the sleep-­
wake disorders can be found in Table 5.

 exual Dysfunctions, Paraphilic Disorders, and Gender

S
Dysphoria

In terms of sexual disorders, it is hard to clearly differentiate normal sexual behavior

from distorted or maladaptive sexual behavior. This difficulty stems from differ-
ences in behavior that is considered acceptable in different cultures, as well as from
different genders. For example, Asian countries place a much higher value on femi-
nine virginity, and social control over feminine sexuality is typically very strong.
Conversely, among developed individualistic western countries such as the US, a
higher degree of sexual activity, including premarital sex, is generally accepted
(Ubillos, Paez, & González, 2000).
In terms of diagnosing sexual disorders, current views tend to be quite tolerant
of a variety of sexual expression, unless the behavior is associated with substan-
tial impairment in functioning or involves non-consenting individuals such as
children (Barlow et al., 2016). Unlike the DSM-IV, in which the Sexual and
Gender Identity Disorders constituted one stand-alone chapter, the DSM-5 and
the ICD-10 have three separate chapters for Sexual Dysfunctions, Paraphilic
Disorders/Disorders of Sexual Preference, and Gender Dysphoria/Gender
Identity Disorder. Each category is briefly described, and the specific disorders
are presented in Table 6.

Sexual Dysfunctions

Sexual dysfunctions are a heterogeneous group of disorders that are typically char-
acterized by a clinically significant disturbance in a person’s ability to respond sexu-
ally or to experience sexual pleasure. Research shows that the prevalence of people
with sexual dysfunction can be as high as 45%, but only around 25% of these indi-
viduals expressed significant distress (Bancroft, Loftus, & Long, 2003), which is
required for a diagnosis according to the DSM-5. Sexual dysfunctions occur among
all genders and sexual orientations. This category includes: delayed ejaculation,
erectile disorder, female orgasmic disorder, female sexual interest/arousal disorder,
genito-pelvic pain/penetration disorder, male hypoactive sexual desire disorder,
20 S. Eldar et al.

Table 5 Description of sleep-wake disorders

Category Disorder Description
Dyssomnias Insomnia disorder Difficulties falling and staying
Problems in the asleep, and not feeling rested, even
amount, timing or after sleeping
quality of sleep Hypersomnolence disorders Excessive sleeping at night, or
frequent falling asleep during the day
Narcolepsy Poor control of sleep-wake cycles.
With periods of extreme daytime
sleepiness and sudden, irresistible
bouts of sleep
Breathing-related sleep A variety of breathing problems that
disorders occur during sleep and that lead to
hypersomnia or insomnia
Circadian rhythm sleep-­ When sleep times are out of
wake disorder alignment, thus sleep times are not
normal at night
Parasomnias Disorders of arousal Motor movements and behaviors that
Abnormal events that occur during sleep including
occur during sleep or incomplete awakening (confusional
just upon awakening arousal), sleep walking, or sleep
terrors (waking up with a panicky
scream)
Nightmare disorder Frequently awakened with detailed
and vivid recall of intensely
frightening dreams, usually
involving threats to survival, security
or self-esteem
Rapid eye movement sleep Episodes of arousal during sleep in
behavior disorder which the individual engages in
activities associated with waking,
without actually being awake (e.g.
acting out dreams)
Restless legs syndrome A relatively common phenomenon
that involves urges to move the legs
as a result of unpleasant sensations
Substance-induced sleep Sleep disturbance that is the result of
disorder substance use

premature ejaculation, substance/medication-induced sexual dysfunction, and other

specified or unspecified sexual dysfunction. An individual may have several sexual
dysfunctions at the same time (Balon, Segraves, & Clayton, 2007).
Sexual dysfunctions are interdependent with psychosocial and biological/physi-
ological factors, and diagnosis should include a careful consideration of issues such
as the partner’s emotional or personality problems, quality of the relationship, indi-
vidual vulnerability, cultural or religious attitudes toward sexuality, and medical
factors relevant to prognosis, course, or treatment.
Psychopathology and Classification 21

Paraphilic Disorders/Disorders of Sexual Preference

Paraphilia means strong attraction to abnormal stimuli. Paraphilic disorders are

diagnosed when sexual arousal occurs primarily in the context of inappropriate or
atypical objects or individuals, and is associated with distress and impairment, or
harm to others. The DSM-5 section on paraphilic/sexual disorders includes the most
common disorders, as well as those classified as criminal offenses, and are orga-
nized into two groups of disorders. The first is based on anomalous activity prefer-
ences. These disorders are subdivided into courtship disorders, which resemble
distorted components of human courtship behavior (voyeuristic disorder, exhibi-
tionistic disorder, and frotteuristic disorder), and algolagnic disorders, which
involve deriving sexual pleasure from physical pain (sexual masochism disorder
and sexual sadism disorder). The second group of disorders is based on anomalous
sexual target preferences. These disorders include one directed at other humans
(pedophilic disorder), and two directed elsewhere (fetishistic disorder and transves-
tic disorder). It is important to note that for all these disorders, the presence of a
paraphilia does not itself justify a diagnosis, but must also be accompanied by clini-
cally significant distress, functional impairment, or harm to non-consenting others.
The population prevalence of most of these disorders is unknown, and estimates
vary widely from 2 to 30% across disorders. Usually the prevalence among males is
higher than in females (Konrad, Welke, & Opitz-Welke, 2015).

Table 6 Description of sexual dysfunctions, paraphilic disorders, and gender dysphoria

Category Disorder Description
Sexual Delayed ejaculation Marked delay, infrequency, or absence
dysfunctions of ejaculation
Erectile disorder Marked difficulty in obtaining or
maintaining an erection or decrease in
erectile rigidity
Female orgasmic disorder Delay, infrequency, absence, or
reduction in experiencing orgasm
Female sexual interest/arousal Lack of, or significantly reduced,
disorder sexual interest or arousal
Genito-pelvic pain/penetration Difficulties, pain, tension, or anxiety
disorder related to vaginal penetration
Male hypoactive sexual desire Deficient or absent sexual/erotic
disorder thoughts, fantasies, or desire for
sexual activity
Premature (early) ejaculation Pattern of ejaculation occurring very
early during sexual activity and before
the individual wishes it
Substance/medication-induced A clinically significant disturbance in
sexual dysfunction sexual function caused by exposure to
a substance or medication
(continued)
22 S. Eldar et al.

Table 6 (continued)
Category Disorder Description
Paraphilic Voyeuristic Recurrent and intense sexual arousal
disorders from observing an unsuspecting
person who is naked, in the process of
disrobing, or engaging in sexual
activity
Exhibitionistic disorder Recurrent and intense sexual arousal
from the exposure of one’s genitals to
an unsuspecting person
Frotteuristic disorder Recurrent and intense sexual arousal
from touching or rubbing against a
non-consenting person
Sexual masochism disorder Recurrent and intense sexual arousal
from the act of being humiliated,
beaten, bound, or otherwise made to
suffer
Sexual sadism disorder Recurrent and intense sexual arousal
from the physical or psychological
suffering of another person
Pedophilic disorder Intense sexually arousing fantasies,
sexual urges, or behaviors involving
sexual activity with a prepubescent
child (generally age 13 years or
younger)
Fetishistic disorder Recurrent and intense sexual arousal
from either the use of nonliving
objects or a highly specific focus on
non-genital body part(s)
Transvestic disorder Recurrent and intense sexual arousal
from wearing clothes typical of the
opposite sex
Gender Under this category are gender A marked incongruence between
dysphoria dysphoria; other specified gender one’s experienced/expressed gender
dysphoria; unspecified gender and assigned/biological sex
dysphoria

Gender Dysphoria/Gender Identity Disorder

Gender dysphoria refers to cases where a person’s biological sex is not consistent
with what they experience as their correct gender. The diagnosis is given when this
inconsistency is associated with clinically significant distress or impairment.
Individuals with this disorder often feel trapped in a body of the wrong sex, and
wish to live life openly in a manner consistent with that of their self-identified gen-
der. The prevalence of gender dysphoria ranges from 0.002 to 0.014% (Dhejne,
Öberg, Arver, & Landén, 2014).
Expression of gender dysphoria varies with age. Young children are less likely
than older children, adolescents, and adults to express extreme and persistent
Psychopathology and Classification 23

a­ natomic dysphoria. In adolescents and adults, incongruence between experienced

gender and somatic sex is a central feature of the diagnosis. Factors related to dis-
tress and impairment also vary with age. A very young child may show signs of
distress (e.g., intense crying) only in specific situations in which they are reminded
of their divergent gender identification. In adolescents and adults, distress may man-
ifest because of strong incongruence between experienced gender and somatic sex.
Such distress may, however, be mitigated by supportive environments and knowl-
edge that biomedical treatments exist to reduce incongruence (APA, 2013).

Disruptive, Impulse-Control and Conduct Disorders

Under this category are disorders involving problems in the self-control of emotions
and behaviors. In the ICD-10, most of these disorders fall under the same category
as personality disorders, though some are in the developmental disorders section.
The disruptive behavior disorders are manifested in behaviors and habits that vio-
late the rights of others (e.g., aggression, destruction of property) and/or that bring
the individual into significant conflict with societal norms or authority figures. Since
some of these behaviors can occur to some degree in typically developing individu-
als, the diagnosing clinician must consider the frequency and pervasiveness of
behaviors across multiple contexts, the impairment associated with these behaviors.
Furthermore, it is particularly important that behaviors be assessed relative to what
is normative for a person’s age, gender, and culture. These disorders tend to be more
common in males than in females, and to onset in childhood or adolescence.
Oppositional defiant disorder. Defined as a frequent and persistent pattern of angry/
irritable mood (e.g. losing temper), argumentative/defiant behavior (e.g. blaming
others for their mistakes), or vindictiveness. The disturbance in behavior is associ-
ated with distress in the individual or others that are close to them.
Intermittent explosive disorder. Describes a pattern of poorly controlled emotions
and verbal or physical outbursts of anger towards property, animals or other indi-
viduals. These behaviors are disproportionate to the interpersonal or other provoca-
tion, or to other psychosocial stressors.
Conduct disorder. Focuses largely on poorly controlled behaviors that violate the
rights of others or that violate major societal norms (e.g. bullying others, initiating
physical fights, being cruel, etc.). Conduct disorder is one of the few disorders to
include in its criteria specific legal or social offenses (e.g. larceny, truancy).
Pyromania and kleptomania. Less common diagnoses characterized by poor
impulse control related to specific behaviors (fire setting and stealing, respectively)
that relieve internal tension.
24 S. Eldar et al.

Schizophrenia Spectrum and Other Psychotic Disorders

Schizophrenia is a complex syndrome affecting 1% of the population, irrespective

of culture, class or race. The first episode of schizophrenia often occurs when a
person is in their late adolescence or early adulthood and the course of the illness is
variable. Some signs of the development of the disorder may be visible in child-
hood. This disorder can disrupt a person’s perception, thought, speech, and move-
ment and hence has a devastating effect on the individual and their family members.
The prognosis of schizophrenia is poor, and recovery is very rare.
The symptoms of schizophrenia are varied, and can manifest differently among
individuals. Some people have difficulties with their thoughts, making illogical
associations and developing false and sometimes bizarre explanations (i.e., delu-
sions) for their experiences or symptoms. Problems with false perceptions may also
occur, for example hearing voices or seeing visions (i.e., hallucinations). Difficulties
with concentration, attention and motivation may also lead to poor social and occu-
pational functioning. The range of emotional expression, capacity to think and act
may be reduced, together with an inability to experience pleasure (Jones, Hacker,
Cormac, Meaden, & Irving, 2012). It is customary to view the symptoms of schizo-
phrenia as falling into three broad categories: (1) ‘positive’ symptoms, which are
unusual by their presence (for example, hearing voices); (2) ‘negative’ symptoms,
which are unusual by their absence (for example, restricted range and intensity of
emotional expression); and (3) disorganized symptoms, which are erratic behaviors
that affect speech, motor behaviors and emotional reactions. A diagnosis of schizo-
phrenia requires continuous signs of disturbance for at least 6 months, including at
least one month in which two or more symptoms are active, and at least one symp-
tom is delusions, hallucinations or disorganized speech.
Some psychotic behaviors do not fit under the title of schizophrenia. Table 7
presents other psychotic disorders as they are described in the DSM-5.

Personality Disorders

The personality disorders (PD) describe a persistent pattern of emotions, cognitions,

and behaviors that results in enduring emotional distress for the person affected and/
or for others. These symptoms deviate markedly from the expectations of the indi-
vidual’s culture, and are pervasive and inflexible, thus frequently cause difficulties
with work and social relationships, and lead to distress or impairment. The onset of
PDs is usually in adolescence or early adulthood, and since the symptoms follow a
chronic course, they pervade every aspect of the person’s life (APA, 2013; Widiger,
2012). Certain personality disorders (e.g., antisocial personality disorder) are diag-
nosed more frequently in males; others (e.g., borderline, histrionic, and dependent
personality disorders) are diagnosed more frequently in females. The worldwide
prevalence of PDs is estimated around 6% of adults (Quirk et al., 2016).
Psychopathology and Classification 25

When diagnosing PDs, the clinician must understand an individual’s symptoms

in their sociocultural context, considering the dynamic interaction between person-
ality traits, developmental histories of adversity, and the current social context
(Ryder, Sunohara, & Kirmayer, 2015). Additionally, the diagnostic criteria specify
that the impairments in personality functioning cannot better be explained by
another mental disorder, the physiological effects of a substance, or another medical
condition (Möller et al., 2015).
Both the DSM-5 and ICD-10 use a categorical approach to diagnosing PDs (i.e.
PDs are qualitatively distinct clinical syndromes that are different from psychologi-
cally healthy behaviors). However, Section III of the DSM-5 includes a dimensional
diagnostic approach, in which individuals are rated on a series of personality
­dimensions (e.g. personality functioning, traits, etc.) (APA, 2013; Möller et al.,
2015). Table 8 summaries the main personality disorders.

Neurodevelopmental Disorders

This category includes disorders presumed to have a neurological etiology, com-

monly onset early in life, and persist throughout the lifespan. The range of develop-
mental deficits varies from very specific limitations of learning or control of
executive functions, to global impairments of social skills or intelligence. Clinical
descriptions of the main disorders in this category are presented in Table 9.

Neurocognitive/Organic Disorders

As opposed to the neurodevelopmental disorders that are believed to be present

from birth, the neurocognitive disorders typically develop much later in life. The
DSM-5 gathers these disorders under the new title of neurocognitive disorders. In
the past these disorders were under the category of “organic mental disorders” (this
name is still being used in the ICD-10), or “cognitive disorders,” but these titles
were confusing in their descriptive overlap with other disorders categories.
The main disorders under this category are Delirium and Dementia; the ICD-10
also includes organic mental disorders due to brain injury or other physical prob-
lems. Delirium is characterized by impaired consciousness (e.g. attention and
awareness) and cognitions (e.g. memory and language) during the course of several
hours or days. In most cases, delirium appears after improper use of medications,
especially among elderly population who tend to use prescription medications more
than any other group. Dementia, or major neurocognitive disorder (according to
DSM-5) is a gradual deterioration of brain functioning that affects memory, judg-
ment, language and other advanced cognitive processes. The DSM-5 distinguishes
between major neurocognitive disorders, and mild neurocognitive disorders, the lat-
ter being a new classification in the DSM-5. The distinction between the two is
primarily one of severity and may correspond in most progressive disorders
26 S. Eldar et al.

Table 7 Description of psychotic disorders

Disorder Description
Delusional Persistent beliefs that are contrary to reality, in the absence
of other characteristics of schizophrenia
Schizophreniform Similar symptoms as schizophrenia, but with a different
time course: The total duration of the illness, including
prodromal, active, and residual phases, is at least 1 month
but less than 6 months
Schizoaffective Presence of a mood episode (major depressive or mania) in
addition to delusions or hallucinations for at least 2 weeks
Catatonia Marked psychomotor disturbance, including at least three
of the 12 diagnostic features of catatonia (e.g., stupor,
catalepsy, mutism, negativism)
Brief psychotic Presence of delusions, hallucinations, disorganized speech
or catatonic behavior for at least 1 day, but less than a
month
Substance/medication-induced Prominent delusions and/or hallucinations that are judged
psychotic to be due to the physiological effects of a substance/
medication
Psychotic disorder due to another Psychotic symptoms are judged to be a direct physiological
medical condition consequence of another medical condition

with earlier and later stages of the disease (Möller et al., 2015). Mild neurocognitive
disorder is focused on the early stages of cognitive decline, in which the cognitive
deficits do not interfere with capacity for independence in everyday activities. The
different diagnoses refer to the cause of the neurocognitive disorder, such as medi-
cal conditions (e.g. Alzheimer’s disease, HIV infection), abuse of drugs or alcohol,
or trauma to the brain.

Summary and Conclusion

This chapter has focused on descriptions of psychological disorders as they are clas-
sified in the DSM-5 and ICD-10, the two primary diagnostic reference manuals
used by clinicians today. Since their inception, each new edition of these manuals
has been motivated by new research findings that have implications for the classifi-
cation of psychological disorders. Accordingly, the history of these revisions reflects
the changing landscape of how psychologists have conceptualized the key causes
and characteristics of mental illness, as well as shifting political influences on fund-
ing for psychological research (Mayes & Horwitz, 2005). For example, the first
edition of the DSM was published in 1952, a period in which Freudian psychoana-
lytic theories still dominated the field. Consequently, this first edition described
most disorders as having a predominately psychodynamic etiology, stemming from
dysfunctional or traumatic experiences in infancy or early childhood (Grob, 1991).
Since then, psychological research has demonstrated that both biological and
cognitive mechanisms also contribute to the etiology and maintenance of p­ sychological
Psychopathology and Classification 27

Table 8 Description of personality disorders

Personality disorder Description
Paranoid Distrust and suspiciousness of others, including distorted
interpretations of others’ actions as malevolent and directed
towards the individual
Schizoid Detachment from social relationships, restricted range of emotional
expression, and a preference for solitary activities
Antisocial/dissocial Disregard for and violation of the rights of others, incapacity for
social empathy, and irresponsible or violent attitudes towards
societal norms, rules and obligations
Borderline Instability of interpersonal relationships, self-image, affect, and
control over impulses
Histrionic Excessive emotional expression, attention seeking, and shallow
affect
Avoidant/anxious Social inhibition, feelings of inadequacy, and hypersensitivity to
negative evaluation
Dependent An excessive need to be taken care of, leading to submissive and
clinging behavior and fears of separation
Obsessive-compulsive/ Preoccupation with orderliness, perfectionism, and mental and
Anankastic interpersonal control, at the expense of flexibility, empathic
personal relations, and productivity
Organic Disinhibited social behaviors, extreme emotional lability (apathy,
euphoria or irritability), and cognitive disturbances such as
paranoia, reduced perseverance of actions, and impaired language
production; these symptoms stem from an objective cerebral
disease, damage or dysfunction
Impulsive type Impulsive behaviors without consideration of the consequences,
some related to unstable mood and outbursts of anger and violence
Schizotypal Social and interpersonal deficits marked by acute discomfort and
reduced capacity for close relationships, as well as cognitive or
perceptual distortions and eccentricities of behavior
Narcissistic personality Grandiosity (in fantasy or behavior), need for admiration, and lack
disorder of empathy

disorders (Stein et al., 2010). In particular, genetics research and translational

­neurobiology have revealed strong links between heritable biomarkers and the
expression of certain psychological disorders (Kendler, 2012). As mentioned at the
beginning of this chapter, the development of the DSM-5 involved heated debate
over the dimensional vs. categorical nature of psychopathology, and premise of the
existence of disease entities. Many members of the psychiatric community have
been dissatisfied with the sole reliance on verbal report and clinical impressions to
assign patients to relatively arbitrary diagnostic categories. This has led to much
public debate around the publication of the DSM-5 that is likely to continue.
This debate and the new wave of translational research it sparked remains strong,
and the stated goal of many influential psychological scientists is that future diag-
nostic criteria will increasingly include biomarkers of disorders (e.g. specific genes
28 S. Eldar et al.

Table 9 Description of neurodevelopmental disorders

Disorder Clinical description
Intellectual disability The individual fails to meet expected developmental
milestones in several areas of intellectual functioning,
such as reasoning, problem solving, planning, abstract
thinking, judgment, academic learning, and learning
from experience
Communication disorders (language These disorders are characterized by deficits in the
disorder, speech sound disorder, social development and use of language, speech, and social
(pragmatic) communication disorder, communication; and by disturbances of the normal
and childhood-onset fluency disorder) fluency and motor production of speech
Autism spectrum disorder Persistent deficits in social communication and social
interaction across multiple contexts, including deficits
in social reciprocity, nonverbal communicative
behaviors used for social interaction, and skills in
developing, maintaining, and understanding
relationships. In addition, restricted, repetitive patterns
of behavior, interests, or activities have to be present
Attention-deficit/hyperactivity disorder Impairing levels of inattention, disorganization, and/or
(ADHD) hyperactivity-impulsivity across multiple contexts
Neurodevelopmental motor disorders Disorders of the nervous system that cause abnormal
(developmental coordination disorder, and involuntary movements
stereotypic movement disorder, and tic
disorder)
Specific learning disorder Specific deficits in an individual’s ability to perceive
or process information efficiently and accurately.
Characterized by persistent and impairing difficulties
with learning foundational academic skills in reading,
writing, and/or math

or patterns of neurochemistry) as they are unveiled by progressing research (Kapur,

Phillips, & Insel, 2012). Though these goals are lofty and will take decades of dedi-
cated research to achieve, progress has been made in identifying key biological
characteristics of certain disorders. The Psychiatric Genetics Consortium has made
great strides in identifying genetic markers of a number of disorders, including a
recently published study identifying 108 independent genetic loci associated with
schizophrenia (Ripke et al., 2014). However, it should be noted that the genetic vari-
ance to virtually any form of psychopathology is too small to make a meaningful
contribution to nosology. Moreover, the premise of the latent disease entities (as
implied by biological abnormalities and genetic markers) has to be critically exam-
ined. The complex network perspective offers a fresh new look at this issue.
Although the recent emphasis on identifying biomarkers has dominated many
programs of psychological research, the goal of improving the classification of psy-
chological disorders is not limited to biological or translational work. For example,
some researchers have approached the issue of improving diagnostic validity by
emphasizing a cross-informant approach. While child and adolescent psychology
have more commonly utilized a multi-informant approach to the assessment of psy-
chological symptoms (e.g. child, parent, and teacher reports), adult psychology
Psychopathology and Classification 29

relies exclusively on client self-report. A meta-analysis examining 51,000 articles

published over 10 years found that only 108 (0.2%) of these articles utilized a cross-­
informant approach to diagnosis; among these, the mean cross-informant correla-
tion ranged between .304 and .681, indicating wide variability between diagnoses
obtained using self- and informant-reports (Achenbach, Krukowski, Dumenci, &
Ivanova, 2005). The authors argue that the classification of psychological disorders
can be greatly improved simply by obtaining multiple symptom reports, a process
that is arguably much easier and more cost-effective than a battery of biological
tests. At the same time, most experts would agree that psychiatric nosology has to
move beyond symptom report in order to make significant advances.

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