Posted: March 12th, 2023

Psychiatric

Compare and contrast the attachments. At a minimum, you should address the following in your assignment

Discuss at least two similarities and two differences between the perspectives expressed by the authors of each article.
Discuss your own perspective on the material in the articles and how your views changed or did not change after reading the articles.
In your future PMHNP practice, you will be using the DSM-5-TR to diagnose patients. How will you apply what you learned from the articles when diagnosing and treating patients?

Criteria for success:

Fully answer all of the prompts in detail.
Show evidence of scholarly analysis and synthesis of the materials. Go beyond repeating the authors’ perspectives.

CRJ322

Criminology Theory Application Chart

Instructions

For each of the 10 scenarios, specify:

The crime committed and the underlying cause of the behavior, based on criminology theories.

A police response to the scenario that addresses the behavior and provides a solution to the incident.

Note:

The first scenario is completed for you as a guide to completing the remaining nine scenarios.

Remember to use SWS to properly cite your sources.

Scenario

Crime Committed and Causation

Police Response

Example Scenario: You are dispatched to a local grocery store. Upon arrival, you find the store manager is holding a woman he claims tried to leave the store with a cart of groceries. You observe the cart is filled with loaves of bread, peanut butter, eggs, diapers, baby formula, cheese, etc. You ask the woman for her side of the story. She tells you she is a single mom of four kids and has lost her job. She is on the verge of losing her home, and she needed to feed her children. She tells you she didn’t know what else to do.

The suspect in this case has allegedly committed the crime of retail theft, or shoplifting. One explanation behind the cause of this offense is Robert Merton’s Strain Theory. According to Strain Theory, strain occurs when a gap exists between a person’s goals and the means by which they can achieve them. In this case, the woman’s goal is to feed her family; no money represents the lack of means. People adapt to their strain in a variety of ways. In this case, the woman adapted as an innovator. She came up with a different means to achieve her goal, although illegal.

Police have discretion when it comes to a situation like this. An officer has the legal authority to arrest this woman for the offense. However, that might not be the best choice of action. The officer could consider paying for the items for the woman so that she could feed her family. Alternately, the officer could offer information on other means to obtain food for her family such as churches or foodbanks.

Scenario 1:
You are dispatched to your favorite convenience store, the one with free coffee and fresh donuts. Upon your arrival, the manager tells you a man that looks homeless is outside the store begging customers for money. The manager tells you he told the man to leave the property. The man wouldn’t leave and continues to harass customers.
You speak with the man outside of the store. He tells you he is a US Army veteran suffering from PTSD as a result of combat during The Gulf War.

Scenario 2:
You receive a call for a domestic in progress a few blocks from where you are. You arrive at the scene and approach the front door. A woman with a bloody nose, a scratch above her eye and clear defensive wounds on her hands and forearms meets you at the door. She tells you she is all right and does not require medical attention. When you ask what happened, she invites you into the house.
Once inside, you notice a male in his late teens. The knuckles on his right hand are red and swollen. You also notice he is on the floor playing with Matchbox cars while Sesame Street plays on the television in the background. The woman explains she is the boy’s mother and that he is autistic and can sometimes have violent reactions in situations where he feels he doesn’t get his way.

Scenario 3:
You receive a call about a stolen bicycle. The stolen bicycle’s owner tells you he saw who took it. He explains that he watched his neighbor, a 15-year-old juvenile, walk into the garage and wheel the bike out.
You go to the neighbor’s home and speak to the 15-year-old juvenile and his mom. The juvenile explains that he did take the bike. He tells you he really wanted a bike; all his friends have bikes, and they are always riding off together without him. He further explains that he deserved the bike. He is doing well in school and never gets into trouble. He knows his mom can’t afford to buy him his own bike. He also tells you the bike’s owner never rode it. It just sat in the garage. He doesn’t think he’s hurting anyone.

Scenario 4:
You are a school resource officer at the local high school. You are at the school during normal school hours when you receive a call from one of the math teachers. She informs you one of her female students is being very disruptive and disrespectful and needs to be removed from the class. When you arrive at the classroom, the teacher identifies the difficult student and asks you to remove her.
When you speak to the student, she ignores you. You make several attempts to engage the student, but she refuses to respond. You also notice she is gripping the desk with her hands to the point that her knuckles have turned white.

Scenario 5:
You are on patrol and you are running radar on the highway. You “clock” a vehicle traveling at 80 MPH in a 65 MPH zone. You pull out and execute a traffic stop on the vehicle. During the course of your investigation into the stop, you learn that this is the fifth time this driver has been stopped for speeding in the last 8 months.
You ask the driver about this. She responds, “I like to drive fast.”

Scenario 6:
It is 0200 hours (2:00 AM). You are on patrol with your partner. He is complaining about the low pay, long hours and difficult work. You receive a call about a security alarm at a convenience store. The store closed at midnight. No one should be there. You arrive to find the back door slightly ajar. You and your partner go in and perform a thorough search and find no problems. It’s possible an employee failed to secure the door. You contact dispatch and ask them to notify the store owner of your findings.
As you get ready to leave, you see your partner take a bottle of soda and a bag of chips from the store. He looks at you and says, “Payment for services rendered” and walks out to the patrol car.

Scenario 7:
You are walking the beat on foot patrol when you notice several juveniles standing on the street corner. As you continue to walk in their direction, you clearly observe one juvenile hand the other money in exchange for a clear baggie containing a white powder. You announce yourself as a police officer and tell them not to move. They begin to run and you give chase. You catch one of the juveniles and take him into custody without further incident. You conduct a lawful search of the juvenile and find a wad of cash and 5 small clear baggies containing a white powder (later to be confirmed as cocaine). During your search, you also notice a tattoo on the juvenile’s neck that instantly tells you he is a member of the local gang.

Scenario 8:
You receive a call about a theft at a local electronics store. Upon arriving at the store, you learn that security is holding a young teenager for trying to steal a cell phone and tablet. The store’s security system captured video of the juvenile stuffing these items into his pants before trying to leave the store.
You ask the child his name; you recognize it. You find out you have the child of a repeat offender who has been accused and convicted of property crimes in the area over the course of many years.

Scenario 9:
You are on patrol working in plain clothes and driving an unmarked car. You drive through an area known for prostitution when you come to a stop at a red traffic light at an intersection. As you wait for the light to turn green, a woman comes to your passenger-side window and propositions you. She tells you for $20.00, she will “go all the way.” The woman is emaciated looking and wearing tattered clothes. As she leans against your car, you notice groupings of needle marks on her arms.

© 2020 Strayer University. All Rights Reserved. This document contains Strayer University Confidential and Proprietary information and may not be copied, further distributed, or otherwise disclosed in whole or in part, without the expressed written permission of Strayer University.

Page 2 of 10

image1

What makes a good psychiatrist? What particular skills are needed
to practice a ‘medicine of the mind’? Although it is impossible to
answer such questions fully we believe that there is mounting
evidence that good practice in psychiatry primarily involves
engagement with the non-technical dimensions of our work such
as relationships, meanings and values. Psychiatry has thus far been
guided by a technological paradigm that, although not ignoring
these aspects of our work, has kept them as secondary concerns.
The dominance of this paradigm can be seen in the importance
we have attached to classification systems, causal models of
understanding mental distress and the framing of psychiatric care
as a series of discrete interventions that can be analysed and
measured independent of context.1

In recent years this Journal has published a series of editorials
arguing that the profession should adopt an even more
technological and biomedical identity, and that psychiatrists
should focus on their mastery of technology to allow progress
in the development of brain research, genetics, pharmacology
and neuroradiology.2–4 These resonate with calls in North
America for psychiatry to become simply a ‘clinical neuroscience’.5

However, the promise of therapeutic gains from the brain sciences
always seems to be for the future, leading some to interrogate their
contribution to advances in our field.6 Indeed, neuroscientists
themselves have become more cautious about the value of
reductionist approaches to understanding the nature of human
thought, emotion and behaviour.7,8 Furthermore, there is ample
evidence that anti-stigma campaigns based on biogenetic models
of serious mental illness have been counterproductive.9

The increasing focus on neuroscience has meant that other
important developments in the provision of care and support
for people with mental health problems over the course of the past
century have been neglected. Historically, these have been driven
mostly by non-technical changes that have fostered empowerment
and social inclusion.10 It is generally agreed that the closure of the
large Victorian asylums improved patients’ quality of life. But this
was mainly the result of economic imperatives combined with a
growing realisation of the negative effects of institutionalisation,
rather than, as frequently suggested, a consequence of the
introduction of new drugs.11,12 Other positive developments have
resulted from the establishment of multidisciplinary, community-
based care and the rise of the service user movement and

voluntary sector supports. Many psychiatrists have worked hard
to promote these developments but the increasing focus on
technical and biomedical aspects of care have served to sideline
such efforts.

The technological paradigm

Since its origins in the asylums of the 19th century,13 psychiatry
has faced a fundamental question: can a medicine of the mind
work with the same epistemology as a medicine of the tissues?
Through the 19th and 20th centuries, psychiatry held fast to the
idea that mental health problems are best understood through
a biomedical idiom; that problems with feelings, thoughts,
behaviours and relationships can be fully grasped with the same
sort of scientific tools that we use to investigate problems with
our livers and lungs. In more recent decades, models of cognitive
psychology, such as ‘information processing’, have been developed
that work with the same technical idiom.14 The ‘technological
paradigm’ that now guides psychiatry incorporates these
perspectives, works with a positivist orientation15 and involves
the following assumptions.

(a) Mental health problems arise from faulty mechanisms or
processes of some sort, involving abnormal physiological or
psychological events occurring within the individual.

(b) These mechanisms or processes can be modelled in causal
terms. They are not context-dependent.

(c) Technological interventions are instrumental and can be
designed and studied independently of relationships and
values.

In the technological paradigm, mental health problems can be
mapped and categorised with the same causal logic used in the rest
of medicine, and our interventions can be understood as a series
of discrete treatments targeted at specific syndromes or symptoms.
Relationships, meanings, values, cultural beliefs and practices are
not ignored but become secondary in importance. This order of
priorities is reflected in our understanding of the training needs
of future psychiatrists, what gets published in journals, what
topics are selected for analysis at conferences, the types of research
that are promoted and how we conceptualise our relationship with
the service user movement.

We suggest that this paradigm has not served psychiatry well.
Ignoring fundamental epistemological issues at the heart of our

430

Psychiatry beyond the current paradigm

{

Pat Bracken, Philip Thomas, Sami Timimi, Eia Asen, Graham Behr, Carl Beuster, Seth Bhunnoo,
Ivor Browne, Navjyoat Chhina, Duncan Double, Simon Downer, Chris Evans, Suman Fernando,
Malcolm R. Garland, William Hopkins, Rhodri Huws, Bob Johnson, Brian Martindale, Hugh Middleton,
Daniel Moldavsky, Joanna Moncrieff, Simon Mullins, Julia Nelki, Matteo Pizzo, James Rodger,
Marcellino Smyth, Derek Summerfield, Jeremy Wallace and David Yeomans

Summary
A series of editorials in this Journal have argued that
psychiatry is in the midst of a crisis. The various solutions
proposed would all involve a strengthening of psychiatry’s
identity as essentially ‘applied neuroscience’. Although not
discounting the importance of the brain sciences and
psychopharmacology, we argue that psychiatry needs to
move beyond the dominance of the current, technological

paradigm. This would be more in keeping with the evidence
about how positive outcomes are achieved and could also
serve to foster more meaningful collaboration with the
growing service user movement.

Declaration of interest
None.

The British Journal of Psychiatry (2012)
201, 430–

434

. doi: 10.1192/bjp.bp.112.109447

Special article

{See editorial, pp. 421–422, this issue.

models does not make them go away. Moreover, it does not yield
results that are consistent with the demands of evidence-based
medicine. Many inside and outside the profession are asking
searching questions that challenge current theory and practice.
For example, Marcia Angell, former editor of the New England
Journal of Medicine, launched a serious attack on the orientation
and practice of modern psychiatry in a series of book reviews last
year.16,17 The technological paradigm underscores a trend towards
the medicalisation of everyday life, which, in turn, is associated
with expanding markets for psychotropic agents. This has drawn
widespread criticism, including from the chair of the DSM-IV
taskforce.18 This process has also led to the corruption of sections
of academic psychiatry through its entanglement with the
pharmaceutical industry, damaging the profession’s credibility in
the process.19

Psychiatry now faces two challenges it cannot ignore. First, a
growing body of empirical evidence points to the primary
importance of the non-technical aspects of mental healthcare. If
we are genuine about promoting ‘evidenced-based’ practice, we
will have to take this seriously. Second, real collaboration with
the service user movement can only happen when psychiatry is
ready to move beyond the primacy of the technical paradigm.
In contrast to the thrust of recent editorials, we argue that
substantive progress in our field will not come from neuroscience
and pharmaceuticals (important as these might be) but from a
fundamental re-examination of what mental healthcare is all
about and a rethinking of how genuine knowledge and expertise
can be developed in the field of mental health.

Empirical evidence that challenges
the current paradigm

Many of our patients benefit from psychiatric care and report
improvements with drug treatments and different forms of
psychotherapy. This is not in doubt. But how do such
improvements come about? We will look at the evidence relating
to therapeutic change in depression and allied conditions first.
We will then look at the evidence for ‘serious mental illness’ (a
term that usually covers syndromes such as ‘schizophrenia’ and
‘bipolar disorder’).

Therapeutic change in depression
and allied conditions

There is strong evidence that improvement in depression comes
mainly from non-technical aspects of interventions. Recent
meta-analyses of drug treatments for depression demonstrate that
drug–placebo differences are minimal.20–23 Even in subgroups of
individuals who are more severely depressed, where differences
have been reported as being clinically significant, they are still
small in absolute terms and may be simply the result of
decreased responsiveness to placebo.24 The placebo effect is a
complex phenomenon involving conscious and unconscious
experiences.25,26 Among other things, it involves the mobilisation
of a sense of hope and meaning27 and it would appear that this is
the principal way in which these drugs work. The psychoactive
effects of antidepressants, such as the sedative effects of tricyclics
and the emotional disengagement produced by selective serotonin
reuptake inhibitors, are also likely to be relevant to their
performance in clinical trials, and may or may not be experienced
as helpful by some individuals. Overall, available evidence does
not support the idea that antidepressants work by correcting a
pre-existing ‘chemical imbalance’.28

Two recent reviews of comparisons of real with ‘sham’
electroconvulsive therapy (ECT) also highlight the importance

of non-technical aspects of this treatment. Rasmussen29 concludes
that ‘substantial proportions of what seemed to be severely ill
patients responded to sham treatment quite robustly’. None of
the studies reviewed by Read & Bentall30 found significant
differences between real and sham ECT after the treatment period.
The Northwick Park study,31 regarded by many as the best
designed controlled study of ECT,32 is often quoted as having
found evidence to support the use of ECT. However, there was
no significant difference, over a 4-week treatment period, between
real and sham ECT on ratings by patients or nurses. The single
positive difference (for a ‘deluded’ group, and perceived by
psychiatrists alone) had disappeared 1 month after the end of
treatment. By 6 months, there was actually a two-point difference
in scores on the Hamilton Rating Scale for Depression in favour of
the sham treatment. It is unlikely that the trial, if designed and
executed now to current trial guidelines, could have been reported
as supporting the use of ECT and it is notable that the researchers,
even then, concluded that: ‘many depressive illnesses although
severe may have a favourable outcome with intensive nursing
and medical care even if physical treatments are not given’.31

Similar conclusions emerge from the literature on psycho-
therapy. Cognitive–behavioural therapy (CBT) is the form of
psychotherapy most widely promoted today. Its proponents argue
that it works by rectifying faulty cognitions that are believed to
cause depression.33 However, several studies have shown that most
of the specific features of CBT can be dispensed with without
adversely affecting outcomes.34 A comprehensive review of
studies of the different components of CBT concluded that there
is ‘ . . . little evidence that specific cognitive interventions
significantly increase the effectiveness of the therapy’.35

The evidence that non-specific factors, as opposed to specific
techniques, account for nearly all the change in therapy is
overwhelming. In their review of the evidence on the effectiveness
of psychotherapy, Budd & Hughes write ‘no clear pattern of
superiority for any one treatment has emerged’.36 Cooper provides
an up-to-date and comprehensive examination of the empirical
research on psychotherapy in general.37 What emerges from
the evidence is that non-specific factors (client variables, extra-
therapeutic events, relationship variables and expectancy and
placebo effects) account for about 85% of the variance in
therapeutic outcomes across the psychotherapy field. In particular,
the relationship between therapeutic alliance and outcome seems
remarkably robust across treatment modalities and clinical
presentations.38 The lack of markedly enhanced outcomes from
the use of specific techniques is not limited to research settings.
For example, in a review of over 5000 cases treated in a variety
of National Health Service settings in the UK, no significant
variance in outcome could be attributed to the specific
psychotherapeutic model used, with non-specific factors such as
the therapeutic relationship accounting for most of the variance
in outcomes.39 This has caused some difficulty in developing
national guidelines. Although the National Institute for Health
and Clinical Excellence (NICE) Quick Reference Guide40 provides
clear and definitive recommendations as to what therapies are
recommended in states of depression, an exploration of the full
guideline (Clinical Guideline 90)22 reveals that, in reality, the
evidence for the superiority of a particular approach is far from
clear-cut.

Recovery from serious mental illness

The move away from a technological paradigm resonates strongly
with key insights from the ‘recovery approach’ to mental
healthcare that has become increasingly influential.10 There is a
growing appreciation that personally meaningful recovery from

431

Psychiatry beyond the current paradigm

Bracken et al

serious mental disorder is not necessarily related to the specific
treatments that are prescribed.41 Research has pointed to the
importance of the therapeutic alliance in determining outcomes.42

Others have pointed to the importance of self-esteem and an
‘internal locus of control’.43 It seems that creating a therapeutic
context that promotes empowerment and connectedness and that
helps rebuild a positive self-identity is of great significance.44,45

The concept of recovery is still in development.46 Evidence
from non-Western settings47 and communities48 reveals that people
recover from serious mental illness through many pathways,
pointing to the crucial importance of respecting diversity in
mental health work, both theoretically and therapeutically.49

At the same time, it is increasingly recognised that specific
technical interventions, such as drugs, have a limited impact on
the overall burden of serious mental illness.50 A meta-analysis
of randomised controlled trials investigating the effectiveness of
first- and second-generation antipsychotic drugs found that, at
best, the improvements seen in two commonly used rating scales
(the Brief Psychiatric Rating Scale and the Positive and Negative
Syndrome Scale) were ‘disappointingly limited’.51 Although the
authors’ caution against the conclusion that antipsychotics have
‘negligible effects in clinical practice’, given their findings, and
those of other groups,52 such a conclusion does not seem
unreasonable. Over-reliance on psychopharmacology as the primary
response to serious mental illness created the conditions for a
blindness towards the serious adverse effects of some psychiatric
drugs, and for a shameful collusion with the pharmaceutical
industry’s marketing campaign that sold the illusion of major
innovations in antipsychotic drugs. The claimed therapeutic
advances were, in fact, ‘spurious’.53 As Kendall put it recently
‘the story of the atypicals and the SGAs [second-generation
antipsychotics] is not the story of clinical discovery and progress;
it is the story of fabricated classes, money and marketing’.54 These
drugs are associated with increased cardiovascular risk.55 Such
iatrogenic effects have been cited as one of the reasons for the
significantly decreased life expectancy of people with mental
illness.56

The balance of evidence does not support the idea that mental
health problems are best grasped through a technical idiom or that
good mental health work can be characterised as a series of
discrete interventions. This is not to say that medical knowledge
and expertise are not relevant, and even vital, in the field of mental
health. However, the problems we grapple with cry out for a more
nuanced form of medical understanding and practice. As
Kirmayer & Gold put it recently ‘Defining psychiatry as applied
neuroscience valorizes the brain but urges on us a discipline that
is both mindless and uncultured’.57 We need to develop an
approach to mental health problems that is genuinely sensitive
to the complex interplay of forces (biological, psychological, social
and cultural) that underlie them and that can be used
therapeutically. The evidence is becoming clear that to improve
outcomes for our patients, we must focus more on contexts,
relationships and the creation of services where the promotion
of dignity, respect, meaning and engagement are prioritised.10

We must become more comfortable with cultural diversity, user
empowerment and the importance of peer support.58

Collaboration with the service user movement

Although patients with mental illness were collectively pursuing
their goals as far back as the 17th century,59 it was not until the
1980s that effective user organisations emerged. Since then the rise
of the movement has been rapid. In the UK alone, it is now
estimated that there are at least 300 groups with an approximate

membership of 9000.60 The service user movement is now
worldwide, with organisations set up by service users consulted
by national governments, the World Health Organization, the
United Nations and the World Psychiatric Association.61

Although some service users are happy to define themselves
and their problems through a biomedical framework, many others
are not. Such groups and individuals hold a variety of views, but
are generally united by a rejection of the technological framework
and the way it defines their problems through an expert
vocabulary and logic. A good example is the Hearing Voices
Network (HVN). This emerged in the Netherlands in the late
1980s, after it was initiated by the psychiatrist Marius Romme.62

It has spread across Europe and America largely through the
efforts of people who hear voices. The HVN is not only a peer
support organisation but also offers a different way of under-
standing and responding to voice hearing. Other organisations,
such as Mind Freedom International and the Icarus Project not
only offer peer support, but also challenge the dominant psycho-
pathological framework. Thus, large sections of the service user
movement seek to reframe experiences of mental illness, distress
and alienation by turning them into human, rather than technical,
challenges.63

There is also evidence that many patients who are not active
in the service user movement find psychiatric interventions
problematic and sometimes harmful. In their study of users’ views
of services, Rogers et al 64 found that many service users did not
really value the technical expertise of the professionals. Instead,
they were more concerned with the human aspects of their
encounters such as being listened to, taken seriously, and treated
with dignity, kindness and respect.

Conclusion

Psychiatry is not neurology; it is not a medicine of the brain.
Although mental health problems undoubtedly have a biological
dimension, in their very nature they reach beyond the brain to
involve social, cultural and psychological dimensions. These
cannot always be grasped through the epistemology of
biomedicine. The mental life of humans is discursive in nature.
As Harré & Gillet put it ‘We must learn to see the mind as the
meeting point of a range of structuring influences whose nature
can only be painted on a broader canvas than that provided by
the study of individual organisms’.14 Reductionist models fail to
grasp what is most important in terms of recovery. The evidence
base is telling us that we need a radical shift in our understanding
of what is at the heart (and perhaps soul) of mental health
practice. If we are to operate in an evidence-based manner, and
work collaboratively with all sections of the service user
movement, we need a psychiatry that is intellectually and ethically
adequate to deal with the sort of problems that present to it. As
well as the addition of more social science and humanities to
the curriculum of our trainees we need to develop a different
sensibility towards mental illness itself and a different under-
standing of our role as doctors.65 We are not seeking to replace
one paradigm with another. A post-technological psychiatry will
not abandon the tools of empirical science or reject medical and
psychotherapeutic techniques but will start to position the ethical
and hermeneutic aspects of our work as primary, thereby
highlighting the importance of examining values, relationships,
politics and the ethical basis of care and caring.

Such a shift will have major implications for our research
priorities, the skills we teach our trainees, the sort of services we
seek to develop and the role we play in managing risk. This
represents a substantial, but exciting, challenge to our profession

432

Psychiatry beyond the current paradigm

to recognise what it does best. We will always need to use our
knowledge of the brain and the body to identify organic causes
of mental disturbance. We will also need knowledge of
psychopharmacology to provide relief from certain forms of
distress. But good psychiatry involves active engagement with
the complex nature of mental health problems, a healthy
scepticism for biological reductionism, tolerance for the tangled
nature of relationships and meanings and the ability to negotiate
these issues in a way that empowers service users and their carers.
Just as operating skills are at the heart of good surgical practice,
skills in working with multiple layers of knowledge and many
systems of meaning are at the heart of our work. We will never
have a biomedical science that is similar to hepatology or
respiratory medicine, not because we are bad doctors, but because
the issues we deal with are of a different nature.

Understanding the unique contribution psychiatry makes to
healthcare can only increase our relevance to the rest of medicine.
All forms of suffering involve layers of personal history, embedded
in a nexus of meaningful relationships that are, in turn, embedded
in cultural and political systems. Kleinman & van der Geest have
rightly critiqued the way in which medicine in general has come to
see ‘caregiving’ in purely technical terms.66 Similarly, Heath has
argued for the importance of relationships and narrative
understanding in general practice.67 Psychiatry has the potential
to offer leadership in this area. Retreating to an even more
biomedical identity will not only sell our patients short, but risks
leading the profession down a single narrow alley, when what is
needed is openness to alternative routes.

Pat Bracken, MD, MRCPsych, PhD, Centre for Mental Health Care and Recovery,
Bantry General Hospital, Bantry, Ireland; Philip Thomas, MPhil, FRCPsych, MD,
University of Bradford, Bradford, UK; Sami Timimi, FRCPsych, Lincolnshire
Partnership NHS Foundation Trust Child and Family Services Horizons Centre, Lincoln,
UK; Eia Asen, MD, FRCPsych, Marlborough Family Service, Central and North West
London Foundation NHS Trust, London, UK; Graham Behr, MRCPsych, Central and
North West London Foundation NHS Trust, London, UK; Carl Beuster, MRCPsych,
Southern Health NHS Foundation Trust, UK; Seth Bhunnoo, MA, MPhil, MRCPsych,
The Halliwick Centre, Haringey Complex Care Team, St Ann’s Hospital, Barnet, Enfield
and Haringey Mental Health NHS Trust, London, UK; Ivor Browne, FRCPI, FRCPsych,
MSc (Harv), DPM, University College Dublin, Dublin, Ireland; Navjyoat Chhina, MA
(Oxon), MSc, MRCPsych, Early Intervention Team, Cumbria Partnership NHS
Foundation Trust, Penrith, UK; Duncan Double, MA, MRCPsych, Norfolk & Suffolk
NHS Foundation Trust, Norwich, UK; Simon Downer, MRCPsych, Severn Deanery
School of Psychiatry, Bristol, UK; Chris Evans, MRCPsych, MSc, MinstGA,
Nottinghamshire Healthcare NHS Trust, Nottingham, UK; Suman Fernando,
FRCPsych, Faculty of Social Sciences & Humanities, London Metropolitan University,
London, UK; Malcolm R. Garland, MD, MRCPI, MRCPsych, St Ita’s Hospital, Portrane,
Ireland; William Hopkins, FRCpsych, Barnet Enfield and Haringey Mental Health NHS
Trust, London, UK; Rhodri Huws, FRCPsych, Eastglade Community Health Centre,
Sheffield, UK; Bob Johnson, MRCPsych, MRCGP, MA, PhD, Rivington House Clinic,
UK; Brian Martindale, FRCP FRCPsych, Northumberland, Tyne and Wear NHS
Foundation Trust, Newcastle upon Tyne, UK; Hugh Middleton, MD, MRCP,
FRCPsych, School of Sociology and Social Policy, University of Nottingham and
Nottinghamshire Healthcare NHS Trust, Nottingham, UK; Daniel Moldavsky,
Specialist Associate RCPsych, Nottinghamshire Healthcare NHS Trust, Nottingham,
UK; Joanna Moncrieff, MRCPsych, Department of Mental Health Sciences, University
College London, London, UK; Simon Mullins, MRCPych, Sheffield Health and Social
Care NHS Foundation Trust, Sheffield, UK; Julia Nelki, FRCPsych, Chester Eating
Disorders Service, Chester, UK; Matteo Pizzo, PGDip, MRCPsych, St Ann’s Hospital,
London, UK; James Rodger, MRCPsych, South Devon CAMHS, Devon Partnership
NHS Trust, Exeter, UK; Marcellino Smyth, MRCPsych, MMedSci, MD, Centre for
Mental Health Care and Recovery, Bantry, Ireland; Derek Summerfield, MRCPsych,
CASCAID, Maudsley Hospital, London, UK; Jeremy Wallace, MSc, MRCPsych, HUS
(Helsinki University Sairaala) Peijas, Vantaa, Finland; David Yeomans, MMedSc
MRCPsych, Leeds & York Partnership NHS Foundation Trust, Leeds, UK

Correspondence: Pat Bracken, MD, MRCPsych, PhD, Centre for Mental Health
Care and Recovery, Bantry General Hospital, Bantry, Co Cork, Ireland. Email:
Pat.Bracken@hse.ie

First received 8 Mar 2012, final revision 10 Jul 2012, accepted 27 Sep 2012

References

1 Radden J. Thinking about the repair manual: technique and technology
in psychiatry. In Philosophical Perspectives on Technology and Psychiatry
(ed J Philips): 263–77. Oxford University Press, 2008.

2 Craddock N, Antebi D, Attenburrow M-J, Bailey A, Carson A, Cowen P, et al.
Wake-up call for British psychiatry. Br J Psychiatry 2008; 193: 6–9.

3 Bullmore E, Fletcher P, Jones PB. Why psychiatry can’t afford to be
neurophobic. Br J Psychiatry 2009; 194: 293–5.

4 Oyebode F, Humphreys M. The future of psychiatry. Br J Psychiatry 2011;
199: 439–40.

5 Insel TR, Quiron R. Psychiatry as a clinical neuroscience discipline. JAMA
2005; 294: 2221–4.

6 Kingdon D, Young AH. Research into putative biological mechanisms of
mental disorders has been of no value to clinical psychiatry. Br J Psychiatry
2007; 191: 285–90.

7 Rose S. The need for a critical neuroscience: from neuroideology to
neurotechnology. In Critical Neuroscience: A Handbook of the Social and
Cultural Contexts of Neuroscience (eds S Choudhury, J Slaby): 53–66.
Wiley-Blackwell, 2012.

8 Vul E, Harris C, Winkelmann P, Pashler H. Puzzlingly high correlations in fMRI
studies of emotion, personality, and social cognition. Perspect Psychol Sci
2009; 4: 319–24.

9 Angermeyer MC, Holzinger A, Carta MG, Schomerus G. Biogenetic
explanations and public acceptance of mental illness: systematic review of
population studies. Br J Psychiatry 2011; 199: 367–72.

10 Slade M. Personal Recovery and Mental Illness. Cambridge University Press,
2009.

11 Gronfein W. Psychotropic drugs and the origins of deinstitutionalization. Soc
Probl 32: 437–54.

12 Aviram U, Syme Sl, Cohen JB. The effects of policies and programs on
reduction of mental hospitalization. Soc Sci Med 1976; 10: 571–7.

13 Porter R. A Social History of Madness: Stories of the Insane. Weidenfeld and
Nicolson, 1987.

14 Harré R, Gillett G. The Discursive Mind. Sage, 1994.

15 Ingleby D. Critical Psychiatry: The Politics of Mental Health. Penguin, 1980.

16 Angell M. The illusions of psychiatry. New York Rev Books 2011,
14 July (http://www.nybooks.com/articles/archives/2011/jul/14/
illusions-of-psychiatry/?pagination = false).

17 Angell M. The epidemic of mental illness: why? New York Rev Books 2011,
23 June (http://www.nybooks.com/articles/archives/2011/jun/23/epidemic-
mental-illness-why/).

18 Frances A. The first draft of DSM-V: if accepted, will fan the flames
of false positive diagnoses. BMJ 2010; 340: c1168.

19 Carey B, Harris G. Psychiatric group faces scrutiny over drug industry ties.
New York Times 2008; 12 July (http://www.nytimes.com/2008/07/12/
washington/12psych.html?pagewanted = all).

20 Andrews G. Placebo response in depression: bane of research, boon to
therapy. Br J Psychiatry 2001; 178: 192–4.

21 Kirsch I, Sapirstein G. Listening to prozac but hearing placebo: a meta-
analysis of antidepressant medication 1998. Prev Treat 1998; 1: 0002a.

22 National Institute for Health and Clinical Excellence (NICE) (2009). Depression:
The Treatment and Management of Depression in Adults. NICE Clinical
Guideline CG90. London: NICE (http://guidance.nice.org.uk/CG90).

23 Fournier JC, DeRubeis RJ, Hollon SD, Dimidjian S, Amsterdam JD, Shelton RC,
et al. Antidepressant drug effects and depression severity: a patient-level
meta-analysis. JAMA 2010; 303: 47–53.

24 Kirsch I, Deacon BJ, Huedo-Medina TB, Scoboria A, Moore TJ, Johnson BT.
Initial severity and antidepressant benefits: a meta-analysis of data
submitted to the Food and Drug Administration. PLoS Med 2008; 5: e45.

25 Thompson JJ, Ritenbaugh C, Nichter M. Reconsidering the placebo response
from a broad anthropological perspective. Cult Med Psychiatry 2009; 33:
112–52.

26 McQueen D, St John Smith P. Placebo effects: a new paradigm and relevance
to psychiatry. Int Psychiatry 2012; 9: 1–3.

27 Moerman D. Meaning, Medicine and the ‘Placebo Effect’. Cambridge
University Press, 2002.

28 Moncrieff J. The Myth of the Chemical Cure: A Critique of Psychiatric Drug
Treatment. Palgrave Macmillan, 2008

29 Rasmussen K. Sham electroconvulsive therapy studies in depressive illness: a
review of the literature and consideration of the placebo phenomenon in
electroconvulsive therapy practice. J ECT 2009; 25: 54–9.

30 Read J, Bentall R. The effectiveness of electroconvulsive therapy: a literature
review. Epidemiol Psichiatr Soc 2010; 19: 333–47.

31 Johnstone EC, Deakin JFW, Lawler P, Frith CD, Stevens M, McPherson K. The
Northwick Park electroconvulsive therapy trial. Lancet 1980; 2: 1317–20.

32 Kendell R. The present state of electroconvulsive therapy. Br J Psychiatry
1981; 139: 265–83.

433

Bracken et al

33 Beck AT. Cognitive therapy: past, present, and future. J Consult Clin Psychol
1993; 61: 194–8.

34 Jacobson NS, Dobson KS, Truax PA, Addis M, Koerner K, Gollan JK, et al. A
component analysis of cognitive-behavioural treatment for depression. J
Consult Clin Psychol 1996; 64: 295–304.

35 Longmore RJ, Worrell M. Do we need to challenge thoughts in cognitive
behaviour therapy? Clin Psychol Rev 2007; 27: 173–87.

36 Budd R, Hughes I. The dodo bird verdict – controversial, inevitable and
important: a commentary on 30 years of meta-analyses. Clin Psychol
Psychother 2009; 16: 510–22.

37 Cooper M. Essential Research Findings in Counselling and Psychotherapy:
The Facts are Friendly. Sage, 2008.

38 Castonguay LG, Beutler LE. Common and unique principles of therapeutic
change: what do we know and what do we need to know? In Principles of
Therapeutic Change that Work (eds LG Castonguay, LE Beutler): 353–69.
Oxford University Press, 2006.

39 Stiles WB, Barkham M, Mellor-Car J. Effectiveness of cognitive-behavioural,
person-centred, and psychodynamic therapies in UK primary-care routine
practice: replication in a larger sample. Psychol Med 2008; 38: 677–88.

40 National Institute for Health and Clinical Excellence (2009) Quick Reference
Guide. Depression: Treatment and Management of Depression in Adults,
including Adults with a Chronic Physical Health Problem. London: NICE
(http://www.nice.org.uk/nicemedia/live/12329/45890/45890 ).

41 Davidson L. Living Outside Mental Illness: Qualitative Studies of Recovery in
Schizophrenia. New York University Press, 2003.

42 Frank AF, Gunderson JG. The role of the therapeutic alliance in the treatment
of schizophrenia. Arch Gen Psychiatry 1990; 47: 228–36.

43 Harrow M, Jobe TH. Factors involved in outcome and recovery in
schizophrenia patients not on antipsychotic medications: a 15-year
multifollow-up study. J Nerv Ment Dis 2007; 195: 406–14.

44 Mancini MA, Hardiman ER, Lawson HA. Making sense of it all: consumer
providers’ theories about factors facilitating and impeding recovery from
psychiatric disabilities. Psychiatr Rehabil J 2005; 29: 48–55.

45 Tew J, Ramon S, Slade M, Bird V, Melton J, Le Boutillier C. Social factors and
recovery from mental health difficulties: a review of the evidence. Br J Soc
Work 2012; 42: 443–60.

46 Leamy M, Bird V, Le Boutillier C, Williams J, Slade M. Conceptual framework
for personal recovery in mental health: systematic review and narrative
synthesis. Br J Psychiatry 2011; 199: 445–52.

47 Raguram R, Venkateswaran A, Ramakrishna J, Weiss MG. Traditional
community resources for mental health: a report of temple healing from
India. BMJ 2002; 325: 38–40.

48 Seebohm P, Henderson P, Munn-Giddings C, Thomas P, Yasmeen S. Together
We Will Change: Community Development, Mental Health and Diversity.
Sainsbury Centre for Mental Health, 2005.

49 Halliburton M. Finding a fit: psychiatric pluralism in South India and its
implications for WHO studies of mental disorder. Transcult Psychiatry 2004;
41: 80–98.

50 Warner R. How much of the burden of schizophrenia is alleviated by
treatment? Br J Psychiatry 2003; 183: 375–6.

51 Lepping P, Sambhi RS, Whittington R, Lane S, Poole R. Clinical relevance of
findings in trials of antipsychotics: systematic review. Br J Psychiatry 2011;
198: 341–5.

52 Bola JR, Kao DT, Soydan H. Antipsychotic medication for early-episode
schizophrenia. Schizophr Bull 2012; 38: 23–5.

53 Tyrer P, Kendall T. The spurious advance of antipsychotic drug therapy.
Lancet 2009; 373: 4–5.

54 Kendall T. The rise and fall of the atypical antipsychotics. Br J Psychiatry
2011; 199: 266–8.

55 Foley DL, Morley KI. Systematic review of early cardiometabolic outcomes of
the first treated episode of psychosis. Arch Gen Psychiatry 2011; 68: 609–16.

56 Thornicroft G. Physical health disparities and mental illness: the scandal of
premature mortality. Br J Psychiatry 2011; 199: 441–2.

57 Kirmayer LJ, Gold I. Re-socializing psychiatry: critical neuroscience and the
limits of reductionism. In Critical Neuroscience: A Handbook of the Social and
Cultural Contexts of Neuroscience (eds S Choudhury, J Slaby): 307–30.
Wiley-Blackwell, 2012.

58 Warner R. Does the scientific evidence support the recovery model?
Psychiatrist 2010; 34: 3–5.

59 Campbell P. The service user/survivor movement. In Mental Health Still
Matters (eds J Reynolds, R Muston, T Heller, J Leach, M McCormick,
J Wallcraft and M Walsh): 46–52. Open University/Palgrave Macmillan, 2009.

60 Wallcraft J, Read J, Sweeney A. On Our Own Terms: Users and Survivors of
Mental Health Services Working Together for Support and Change. Sainsbury
Centre for Mental Health, 2003.

61 MindFreedom. Global Campaign News. MindFreedom, no date (http://
www.mindfreedom.org/campaign/global).

62 Romme M, Escher S. Accepting Voices. MIND, 1993.

63 Stastny P, Lehmann P. Alternatives Beyond Psychiatry. Peter Lehmann
Publishing, 2007.

64 Rogers A, Pilgrim D, Lacey R. Experiencing Psychiatry: Users’ Views of
Services. MacMillan, 1993.

65 Roberts G, Wolfson P. The rediscovery of recovery: open to all. Adv Psychiatr
Treat 2004; 10: 37–48.

66 Kleinman A, van der Geest S. ‘Care’ in health care. Remaking the moral
world of medicine. Med Anthropol 2009; 21: 159–68.

67 Heath I. Divided we fall. The 2011 Harveian oration delivered to the Royal
College of Physicians on October 18th 2011. Clin Med 2011; 11: 576–86.

434

Contents lists available at ScienceDirect

Psychiatry Research

journal homepage: www.elsevier.com/locate/psychres

Heterogeneity in psychiatric diagnostic classification

Kate Allsoppa,b,⁎, John Readc, Rhiannon Corcorana, Peter Kindermana

a Institute of Psychology Health and Society, University of Liverpool, Liverpool, UK
bGreater Manchester Mental Health NHS Foundation

rust, Complex Trauma & Resilience Research Unit, Manchester Academic Health Science Centre, Manchester, UK
c School of Psychology, University of East London, London, UK

A R T I C L E I N F O

Keywords:
Diagnostic model
Assessment
Trauma

A B S T R A C T

The theory and practice of psychiatric diagnosis are central yet contentious. This paper examines the hetero-
geneous nature of categories within the DSM-5, how this heterogeneity is expressed across diagnostic criteria,
and its consequences for clinicians, clients, and the diagnostic model. Selected chapters of the DSM-5 were
thematically analysed: schizophrenia spectrum and other psychotic disorders; bipolar and related disorders;
depressive disorders; anxiety disorders; and trauma- and stressor-related disorders. Themes identified hetero-
geneity in specific diagnostic criteria, including symptom comparators, duration of difficulties, indicators of
severity, and perspective used to assess difficulties. Wider variations across diagnostic categories examined
symptom overlap across categories, and the role of trauma. Pragmatic criteria and difficulties that recur across
multiple diagnostic categories offer flexibility for the clinician, but undermine the model of discrete categories of
disorder. This nevertheless has implications for the way cause is conceptualised, such as implying that trauma
affects only a limited number of diagnoses despite increasing evidence to the contrary. Individual experiences
and specific causal pathways within diagnostic categories may also be obscured. A pragmatic approach to
psychiatric assessment, allowing for recognition of individual experience, may therefore be a more effective way
of understanding distress than maintaining commitment to a disingenuous categorical system.

1. Introduction

Developments and amendments to systems of psychiatric classifi-
cation can be understood within the perspective of wider social and
cultural developments (Foucault,

67). Amongst other consequences,
these socio-political and historical roots have resulted in considerable
inherent heterogeneity in a wide range of psychiatric diagnoses during
their piecemeal development. For example, there are stark differences
between highly specific diagnostic criteria and those with more flex-
ibility around symptom presentation. As a result, there are almost
24,000 possible symptom combinations for panic disorder in DSM-5,
compared with just one possible combination for social phobia
(Galatzer-Levy and Bryant,

13). Olbert and colleagues (2014) also
report considerable heterogeneity within the criteria of individual di-
agnoses, showing that in the majority of diagnoses in both DSM-IV-TR
and DSM-5 (64% and 58.3% respectively), two people could receive the
same diagnosis without sharing any common symptoms. Such ‘dis-
junctive’ categories have been described as scientifically meaningless.
Bannister, for example, pointed out as early as 1968 that the ‘schizo-
phrenia’ construct was ‘[a] semantic Titanic, doomed before it sails, a
concept so diffuse as to be unusable in a scientific context’, largely

because ‘disjunctive categories are logically too primitive for scientific
use’ (Bannister, 1968, pp.

1–182). Young et al. (2014) memorably
calculate that in the DSM-5 there are 270 million combinations of
symptoms that would meet the criteria for both PTSD and major de-
pressive disorder, and when five other commonly made diagnoses are
seen alongside these two, this figure rises to one quintillion symptom
combinations – more than the number of stars in the Milky Way.

Diagnostic heterogeneity is problematic for both research and
clinical practice. The limitations of focusing research on broad diag-
nostic categories over specific difficulties or distressing experiences are
increasingly clear. Research into the relationship between childhood
abuse and subsequent mental health difficulties is hampered by fo-
cusing on diagnostic categories (Read and Mayne, 20

), because the
associations are between specific experiences and symptoms, which
disregard diagnostic clusters. These associations include, for example,
relationships between childhood experiences of loss and avoidance/
numbing, and between childhood sexual abuse and hyperarousal
(Read and Mayne, 2017). Furthermore, extensive research in psychosis
demonstrates specific causal pathways, including between childhood
sexual abuse and hearing voices, and institutionalisation and paranoia
(Bentall et al., 2012). Longstanding focus on diagnostic categories

https://doi.org/10.10

/j.psychres.2019.07.005
Received

April 2019; Received in revised form 26 June 2019; Accepted 1 July 2019

⁎ Corresponding author at: Complex Trauma & Resilience Research Unit, R&I office, 3rd Floor, Rawnsley Building, Hathersage Road, Manchester M13 9WL, UK.
E-mail address: kate.allsopp1@nhs.net (K. Allsopp).

Psychiatry Research 279 (2019) 15–22

Available online 02 July 2019
0165-1781/ © 2019 Elsevier B.V. All rights reserved.

http://www.sciencedirect.com/science/journal/01651781

https://www.elsevier.com/locate/psychres

https://doi.org/10.1016/j.psychres.2019.07.005

mailto:kate.allsopp1@nhs.net

https://doi.org/10.1016/j.psychres.2019.07.005

http://crossmark.crossref.org/dialog/?doi=10.1016/j.psychres.2019.07.005&domain=pdf

means that evidence-based recommendations for interventions, both
drug treatment and psychological therapies, are typically organised by
diagnosis (e.g. National Institute for Health and Care Excellence, 2005;
NICE, 2009), rather than on specific patterns or presentations of dis-
tress, thus recommendations are broad brush rather than in-
dividualised. The clinical implications of these diagnostically focused
recommendations are twofold. First, clients may be referred for a brief
psychological intervention for depression, for example, that follows a
low intensity cognitive behavioural therapy protocol for depression
(NICE, 2009), with little scope for individualised adaptations according
to the specific difficulties experienced by the client. Second, clinicians
must use alternative methods of clinical decision-making to counter the
limitations of heterogeneous diagnostic categories. Drug prescriptions
are rarely made on the basis of a broad diagnosis, but instead according
to the specific symptom presentation of the client (Taylor, 2016). Si-
milarly, more specialised psychological therapy delivered by a clinical
psychologist, for example, is guided by nuanced clinical formulation.
Even psychiatrists may use a ‘diagnostic formulation’ to further expand
upon the broad diagnostic category offered.

Diagnostic heterogeneity is considered in this paper within the ways
that the formal protocol of classification is applied in clinical practice to
serve particular functions, and the impact that heterogeneity can have
in the potential “slippage” (Star and Lampland, 2009, p. 15) between
the two (Suchman, 1987). This study therefore examined the sources of
heterogeneity within and across diagnostic categories. The con-
sequences of heterogeneity were investigated; for clinicians, clients,
and the theoretical conceptualisation of psychiatric diagnoses.

2. Method

For the purposes of manageability, this analysis focussed on five
chapters of DSM-5: schizophrenia spectrum and other psychotic dis-
orders; bipolar and related disorders; depressive disorders; anxiety
disorders; and trauma- and stressor-related disorders. These chapters
were chosen to reflect commonly reported ‘functional’ psychiatric di-
agnoses as highlighted by the Adult Psychiatric Morbidity Survey, in-
cluding ‘common mental disorders’, depression- and anxiety-related
diagnoses (Stansfeld et al., 2016), and PTSD, bipolar, and psychotic
disorder diagnoses (McManus et al., 2016). One common diagnosis
(McManus et al., 2016) that is not contained within the included
chapters is ‘obsessive-compulsive disorder’. Although previously listed
within anxiety disorders in the DSM-IV-TR (American Psychiatric
Association, 2000), the DSM-5 lists this diagnosis within its own
chapter (obsessive-compulsive and related disorders), which contains
numerous other diagnoses that are new and less common, such as
‘trichotillomania’ (hair pulling) and ‘excoriation’ (skin picking). This
chapter, therefore, was excluded for the purposes of this analysis.
Childhood diagnoses (e.g. ‘reactive attachment disorder’; ‘disruptive
mood dysregulation disorder’) were also excluded to enable con-
sideration of diagnostic categories with the potential for consistency
across assessment and reporting (for example, self-reporting of dis-
tress).

2.1. Analysis

Thematic analysis (Braun and Clarke, 2006) was used to code
themes or patterns of meaning across the diagnostic categories being
analysed, with a particular focus on the heterogeneity or differences
across the types of diagnostic criteria. Thematic analysis was used to
identify the ways in which heterogeneity was represented across diag-
nostic categories, and to organise this heterogeneity into central themes
of differences across the criteria. The first phase of the analysis focused
on identifying heterogeneity or differences between the diagnostic
criteria of each category within the five chapters analysed. Four areas of
heterogeneity were identified within specific diagnostic criteria, and
two that spanned across diagnostic categories. During this phase of

coding, data were extracted from each set of diagnostic criteria in each
of the five chapters, and coded line by line to the themes above. Sub-
themes were generated from the information within two codes (Stan-
dards to which symptoms are compared, and Duration of symptoms) as
different ways of representing these themes emerged across diagnostic
categories. The emergent coding framework was reviewed by authors
PK and RC, with the aim of presenting alternative interpretations of the
data. The coding framework was refined accordingly following dis-
cussions.

3. Findings

Heterogeneity in diagnostic criteria was found across each of the
chapters of the DSM-5 that were examined; both within specific types of
criteria, and more broadly across diagnostic categories. These themes
are outlined in Table 1. Unless otherwise specified, page numbers refer
to the DSM-5.

3.1.

Heterogeneity within specific diagnostic criteria

3.1.1. The standards to which symptoms are compared
A key element of heterogeneity stems from differences in the com-

parison of the experience of symptoms with subjectively normal or
assumed normative functioning (or in the omission of such compara-
tors). Diagnostic criteria are represented either by no comparator, or a
change from previous functioning, behaviour, or mood. In particular,
some experiences (such as low mood) are seen as problematic only at a
particular threshold, while other experiences (such as hallucinations)
are indicative of disorder by their presence alone (Table 2).

3.1.1.1. Comparisons with prior experience. Most criteria specifying
either change or comparisons with prior functioning or experience
are mood-related (criteria which are also included within the diagnosis
of schizoaffective disorder). Some descriptions explicitly note a
comparison, for example, criterion A for a major depressive episode
states, “[f]ive (or more) of the following symptoms have been present
during the same 2-week period and represent a change from previous
functioning” (p. 160). Other criteria imply a comparison with previous
mood, for example, criterion A for persistent depressive disorder
(dysthymia) requires “[d]epressed mood for most of the day…” (p.
168); criterion A for a manic episode requires “[a] distinct period of
abnormally and persistently elevated, expansive, or irritable mood and
abnormally and persistently increased goal-directed activity or energy”
(p. 124); criteria B2 and B3 for both manic and hypomanic episodes are
“decreased need for sleep…” and “more talkative than usual…” (p. 124)
respectively. Each of these implies comparison with a usual or
acceptable behaviour or mood, such as sleep, which is altered to a
problematic extent. Some of the criteria for schizophreniform disorder

Table 1
Outline of themes and subthemes.

Heterogeneity within specific diagnostic criteria

The standards to which symptoms are compared
Comparisons with prior experience
Comparison with socially expected responses
No comparators

Duration of symptoms
Minimum duration
No duration
Discrete episodes

Identifiers of severity
Perspective from which distress is assessed

Heterogeneity across diagnostic categories

Symptom overlap across categories
The role of trauma

K. Allsopp, et al. Psychiatry Research 279 (2019) 15–22

and schizophrenia diagnoses also imply a change from usual mood or
motivation, including ‘negative symptoms’, described as “diminished
emotional expression or avolition” (p. 99).

3.1.1.2. Comparison with socially expected responses. Within mood
episodes, and criteria for some anxiety and trauma-related diagnoses,
there is a notion of ‘excessive’ behaviours or responses, suggesting a
comparison with a socially expected response. For example, criterion
B7 of manic and hypomanic episodes requires “excessive involvement
in activities that have a high potential for painful consequences (e.g.
engaging in unrestrained buying sprees, sexual indiscretions, or foolish
business investments)” (p. 124). Criterion B7 of a major depressive
episode assesses “feelings of worthlessness or excessive or inappropriate
guilt…” (p. 125). Separation anxiety disorder similarly assesses
“persistent and excessive worry” (A2, p. 190). In another way of
assessing a person’s response in comparison with expected responses,
specific phobia and adjustment disorder both require the response to be
“out of proportion” (pp. 197, 286), with either the object or situation
(social phobia) or the stressor (adjustment disorder). A subjective
judgement is required to assess whether a person’s experiences are
out of line with typically expected responses. This is discussed further in
the theme of ‘Perspective from which distress is assessed’.

3.1.1.3. No comparators. By contrast, other criteria do not compare
symptoms with a person’s previous experience. This is particularly
apparent for ‘positive symptoms’ of psychosis; the presence of delusions
and hallucinations, for example, is never stated in diagnostic criteria
alongside comparison. Non-compared examples from mood disorder
diagnoses include “feelings of worthlessness” or “recurrent thoughts of
death…” (criteria A7 and A9, respectively, of a major depressive
episode), and “flight of ideas…” or “distractibility…” (criteria B4 and
B5, respectively, of manic and hypomanic episodes). The mood
disorders chapters give a mixed presentation of criteria with both
comparators and no comparators. Three or more of the experiences
described in criterion B must be present for identification of a manic or

hypomanic episode, meaning that presentations of these episodes could
reflect either discontinuous experiences, experiences across a
continuum, or a mixture of the two. The criteria for PTSD and acute
stress disorder notably omit comparators; “[r]ecurrent, involuntary,
and intrusive distressing memories of the traumatic event(s)” (B1, e.g.
p. 271) and “dissociative reactions (e.g. flashbacks)…” (B3, e.g. p. 271)
are examples of criteria for both these diagnoses that are compared
with neither expected responses nor prior functioning. By not using
comparators, these experiences are set up as inherently disordered or
pathological and so are inconsistent with continuum models of
functioning.

The diagnostic criteria for PTSD and acute stress disorder never-
theless require a change in thoughts, behaviours and emotions fol-
lowing trauma. The criteria are also explicit about the severity of
trauma experienced, after which it would be expected that most people
would experience distress. However, there are no comparators to
identify what a ‘normal’ or ‘appropriate’ response to such a severe
stressor would entail. That is, there is no information about how to
identify at what point someone has a ‘disordered’ response as opposed
to one that is ‘normal’. In the case of the criteria for panic disorder,
behaviour change related to panic attacks is constructed as unusual or
unacceptable by what is described as ‘maladaptive’ criteria, despite this
behaviour (such as “behaviors designed to avoid having panic attacks”,
p. 208) representing attempts to cope with the experience of panic at-
tacks.

3.1.2. Duration of symptoms
There were three subthemes representing heterogeneity within the

duration of symptoms or experiences described by diagnostic criteria in
the DSM-5: no duration, discrete episodes, and a minimum duration.
These timeframes effectively construct different ‘kinds’ of disorder ca-
tegories (Table 3).

3.1.2.1. Minimum duration. Most of the analysed diagnostic categories
have a minimum duration requirement. For example, continuous signs

Table 2
The standards to which symptoms are compared.

Subtheme Example from DSM-5

Comparisons with prior experience Major depressive episode: “[f]ive (or more) of the following symptoms have been present during the same 2-week period and
represent a change from previous functioning” (Criterion A, p. 160).
Persistent depressive disorder (dysthymia): “[d]epressed mood for most of the day…” (Criterion A, p. 168)
Manic episode: episode requires “[a] distinct period of abnormally and persistently elevated, expansive, or irritable mood and
abnormally and persistently increased goal-directed activity or energy” (Criterion A, p. 124)
Manic and hypomanic episodes: “decreased need for sleep…” and “more talkative than usual…” (Criteria B2 and B3, p. 124)

Comparison with socially expected responses Manic and hypomanic episodes: “excessive involvement in activities that have a high potential for painful consequences (e.g.
engaging in unrestrained buying sprees, sexual indiscretions, or foolish business investments)” (Criterion B7, p. 124)
Major depressive episode: “feelings of worthlessness or excessive or inappropriate guilt…” (Criterion B7, p. 125)
Separation anxiety disorder: “persistent and excessive worry” (Criterion A2, p. 190)

No comparators Major depressive episode: “feelings of worthlessness” or “recurrent thoughts of death…” (Criteria A7 and A9, p.125)
Manic and hypomanic episodes: “flight of ideas…” or “distractibility…” (Criteria B4 and B5, p.124)
PTSD and acute stress disorder: “[r]ecurrent, involuntary, and intrusive distressing memories of the traumatic event(s)” or
“dissociative reactions (e.g. flashbacks)…” (B1, e.g. p. 271) and (B3, e.g. p. 271)

Table 3
Duration of symptoms.

Subtheme Example from DSM-5

Minimum duration Schizophrenia: “Continuous signs of disturbance for at least 6 months” (Criterion C, p. 99)
Persistent depressive disorder (dysthymia): “at least 2 years of depressed mood” (Criterion A, p. 139)

No duration Difficulties ‘due to other medical conditions’: All chapters, with the exception of trauma-related disorders
Discrete episodes Brief psychotic disorder: A specific duration such as one day to one month (Criterion B, p. 94)

Acute stress disorder: 3 days to 1 month after trauma exposure (Criterion C p. 281).
Adjustment disorders: The symptoms associated with must occur within 3 months of a stressor and not persist for more than 6 months “once the stressor and
its consequences have terminated” (Criterion E, p.287)
The bipolar and related disorders chapter (including, e.g. cyclothymia) and the category of major depressive disorder are unique in that several episodes are
combined in various ways to produce disorders presented as distinct from one another.

K. Allsopp, et al. Psychiatry Research 279 (2019) 15–22

of disturbance for at least 6 months (schizophrenia, Criterion C), or at
least 2 years of depressed mood (persistent depressive disorder –
dysthymia – Criterion A). In the absence of other indicators of
‘disorder’ (such as biomedical markers), a minimum duration
requirement constructs a definition of severity. Giving a minimum
duration criterion creates a way of separating between ‘everyday’
distress and that which is considered ‘cliical’, or otherwise abnormal
and therefore in need of support.

3.1.2.2. No duration. The criteria for certain diagnoses do not use a
timeframe. For example, each chapter (with the exception of trauma-
related disorders) includes difficulties ‘due to other medical conditions’,
with no particular duration needed to meet these criteria. These
diagnoses must be the ‘direct pathophysiological consequence of
another medical condition’ (e.g. p. 120). This use of physiological
signs set these diagnoses apart from other functional diagnoses,
suggesting that functional diagnoses use timeframes to bolster
descriptive diagnoses in the absence of physiological markers.

Other diagnoses that do not require a particular duration are ‘other
specified’ and ‘unspecified’ diagnoses at the end of each of chapter.
These categories have very broad criteria because they are specifically
included to incorporate difficulties that do not meet the criteria for
other diagnoses. The experiences have to be characteristic of other di-
agnoses in their chapter, and cause clinically significant distress or
impairment in functioning (discussed later). However, the ‘unspecified’
diagnoses do not list any criteria, leaving these categories entirely open
to clinical judgement. The ‘other specified’ diagnoses for the schizo-
phrenia spectrum and other psychotic disorders, bipolar and related
disorders and anxiety disorders chapters give options, without dura-
tions, for specified difficulties. For example, ‘persistent auditory hal-
lucinations occurring in the absence of any other features’, a much
briefer criterion than those used for the other diagnoses within the
schizophrenia spectrum and other psychotic disorders chapter.

3.1.2.3. Discrete episodes. Least common are diagnoses that represent
discrete episodes, with a specific duration such as one day to one month
(e.g. brief psychotic disorder) or 3 days to 1 month after trauma
exposure (acute stress disorder p. 281). The symptoms associated with
adjustment disorders must occur within 3 months of a stressor and not
persist for more than 6 months “once the stressor and its consequences
have terminated” (Criterion E, p. 287). These episodic diagnoses
suggest either an expectation of an end point that is not present for
those with a minimum duration, or, more pragmatically, allow
difficulties to be diagnosed (and treated) before the minimum time
period is reached for other diagnoses such as PTSD.

Bipolar and depressive disorders are treated differently again. The
bipolar and related disorders chapter (including, e.g. cyclothymia) and
the category of major depressive disorder are unique in that several
episodes are combined in various ways to produce disorders presented

as distinct from one another. Major depressive and manic episodes are
the two key episodes from which hypomanic episode (shorter duration
and lesser severity than manic episode) and a mixed features specifier
(criteria are met for one episode, with features of another during the
same timeframe) are derived. The three episodes are then variously
combined to create eight different diagnostic categories (seven bipolar-
related diagnoses, and major depressive disorder).

3.1.3. Identifiers of severity
In some cases, severity indicators are prioritised over duration re-

quirements, for example, where hospitalisation or the presence of
psychotic features render consideration of duration unnecessary (manic
episodes and bipolar and related disorders due to another medical
condition). Most categories stipulate a criterion of “clinically significant
distress or impairment in social, occupational, or other important areas
of functioning” (e.g. criterion B, major depressive disorder, p. 161), to
establish a particular threshold for diagnosis (p.

). However, the
threshold is not defined, and therefore represents a subjective judge-
ment, presumably the clinician’s. A separate concept of a marked
change in social, occupational or other areas of functioning (schizo-
phrenia; manic episode) allows the criterion to be met in the absence of
distress. These variations across criteria demonstrate the pragmatic
nature of diagnostic categories and their use as clinical tools. For ex-
ample, if a person’s behaviour is distressing to others, but not to
themselves, the clinician has the flexibility to override the need for
clinically significant distress and make the diagnosis regardless
(Table 4).

DSM-5 contains a dimensional severity rating of 0–4 for each cri-
terion A symptom for delusional, brief psychotic, schizophreniform and
schizoaffective disorder criteria. This may, for example, relate to either
the pressure to respond to voices or delusions or to what extent the
individual is bothered by this experience. For other experiences, such as
disorganised speech, the rating is pragmatically based on clinical ob-
servation rather than the individual’s experience of these difficulties, so
that the individual is not required to recognise their own disordered
speech. Other mood-related diagnoses (bipolar, major depression, and
related disorders) can be rated using a broad dimensional specifier of
mild, moderate, severe, or with psychotic features.

3.1.4. Perspective from which distress is assessed
This theme describes the point of view from which distress or other

diagnostic criteria are assessed, for example, from the account of the
individual being assessed, others around them (e.g. family or friends),
or the assessing clinician. In general, the DSM-5 represents a shift to-
wards the perspective of the observer, whereas several DSM-IV-TR di-
agnoses relied on the individual as the principal (or only) source of
information. For example, for DSM-IV-TR social phobia (social anxiety
disorder in DSM-5), reference is made to “marked distress about having
the phobia” (criterion E) and that the “person recognises that the fear is

Table 4
Identifiers of severity.

Method of identifying severity Example from DSM-5

Clinically significant distress Major depressive disorder;
Post-traumatic stress disorder;
Acute stress disorder:
“Clinically significant distress or impairment in social, occupational, or other important areas of functioning” (e.g. Criterion B, p. 161)

Marked change Schizophrenia: “For a significant portion of the time since the onset of the disturbance, level of functioning in one or more major areas, such as
work, interpersonal relations, or self-care, is markedly below the level achieved prior to the onset…” (Criterion B, p. 99)
Manic episode: “marked impairment in social or occupational functioning…” (Criterion C, p. 124)

Dimensional severity rating Delusional, brief psychotic, schizophreniform and schizoaffective disorders: Dimensional severity rating of 0–4 for each Criterion A symptom for
criteria. This may, for example, relate to either the pressure to respond to voices or delusions or to what extent the individual is bothered by this
experience. For other experiences, such as disorganised speech, the rating is pragmatically based on clinical observation rather than the
individual’s experience of these difficulties

Dimensional specifier Mood-related diagnoses (bipolar, major depression, and related disorders): Can be rated using a broad dimensional specifier of mild, moderate,
severe, or with psychotic features.

K. Allsopp, et al. Psychiatry Research 279 (2019) 15–22

excessive or unreasonable” (criterion C). In comparison, whilst the fears
themselves are self-reported in the DSM-5 version of social anxiety
disorder, the criteria otherwise rely on the perspective of the observer.
Represented within this shift towards the perspective of the observer is
an assumption about insight and the capacity to self-report; an as-
sumption frequently associated with psychotic experiences. However,
this assumption is not explicitly stated in the diagnoses, and therefore
reinforces the fallacious assumption that all people experiencing mental
health problems tend to ‘lack insight’. Thus, the distress criterion is
removed and the individual need not recognise that their fear is ex-
cessive, as the clinician makes this judgement. In another example,
reference to “excessive involvement in activities that have a high po-
tential for painful consequences (e.g. engaging in unrestrained buying
sprees, sexual indiscretions, or foolish business investments)” (manic
and hypomanic episodes, p. 124) constructs a socially accepted level at
which the behaviours are considered normal versus abnormal. The
perspective here demonstrates the power held by the assessing clinician
(or others, such as family) by virtue of the diagnostic criteria sanc-
tioning the making of a value judgement. For other diagnoses, this
person’s perspective is implied but not explicit, for instance, experiences
such as distress and distressing memories, flashbacks and physiological
reactions (PTSD, Criterion B). Finally, in many cases, the question of
perspective (who is making the judgment as to whether the criterion is
met) is unambiguously ambiguous, as in the case of major depressive
episode; “as indicated by subjective report… or observation made by
others”. In a pragmatic approach, information is collected, from a range
of sources, to assess whether or not the diagnostic criteria are met
(Table 5).

3.2. Wider heterogeneity across diagnostic categories

3.2.1. Symptom overlap across categories
Similar or the same experiences occur in multiple diagnostic cate-

gories. Major depressive episode, for example, features within the cri-
teria for major depressive disorder, bipolar and related disorders, and
can be included within the criteria for schizoaffective disorder (for
which criterion A requires the occurrence of “a major mood episode
(major depressive or manic)”, p. 105). Likewise, hallucinations can
occur in schizophrenia and other psychotic disorders, but also in major
depressive disorder with psychotic features, bipolar and related dis-
orders (except cyclothymia), and PTSD (Table 6).

DSM-5 refers to bipolar disorders bridging between psychotic

disorders and depressive disorders, and likewise that schizoaffective
disorder bridges several diagnoses. Despite this repetition of experi-
ences, there is no explicit statement provided in the DSM about the
phenomenological or qualitative experience of symptoms across dif-
ferent diagnoses. The DSM-5 acknowledges,

Although DSM-5 remains a categorical classification of separate
disorders, we recognize that mental disorders do not always fit com-
pletely within the boundaries of a single disorder. Some symptom do-
mains, such as depression and anxiety, involve multiple diagnostic ca-
tegories and may reflect common underlying vulnerabilities for a larger
group of disorders… (p. xli)

Ten specifiers are provided with the DSM-5 to allow the clinician to
represent other patterns not contained within the main diagnostic cri-
teria for bipolar and major depressive disorders, such as with anxious
distress, rapid cycling (for bipolar and related disorders), or psychotic
features. The range of experiences incorporated within these specifiers
acknowledges the heterogeneity of diagnoses. Depressive episodes are
no longer required in DSM-5 criteria for bipolar I, and the diagnostic
criteria for cyclothymic disorder incorporates only experiences that are
sub-threshold for both hypomania and a major depressive episode.
These changes and the additional specifier of ‘anxious distress’ for bi-
polar and MDD diagnoses represents a shift towards broadening the

Table 5
Perspective from which distress is assessed.

Subtheme Example from DSM-5

Self-report Manic and hypomanic episodes: “decreased need for sleep (e.g. feels rested after only 3 h of sleep)” (Criterion B2, p. 124)
Persistent depressive disorder (dysthymia): e.g. “low energy” (Criterion B2, p. 168; “low self-esteem” (Criterion B4, p. 168)
Pre-menstrual dysphoric disorder: e.g. “marked irritability…” (Criterion B2, p. 172); “lethargy” (Criterion C3, p. 172)
Panic disorder: “persistent concern or worry about additional panic attacks…” (Criterion B1, p. 208)
Generalised anxiety disorder: “the individual finds it difficult to control the worry” (Criterion B, p. 222)
Post-traumatic stress disorder: “e.g. “recurrent, involuntary, and intrusive distressing memories of the traumatic event” (Criterion B1, p. 271)

Clinician’s judgement Manic and hypomanic episodes: “During the period of mood disturbance… the following symptoms… are present to a significant degree and
represent a noticeable change from usual behaviour” (Criterion B, p. 124)
Major depressive episode & Major depressive disorder: “psychomotor agitation or retardation… observable by others; not merely subjective
feelings of restlessness or being slowed down” (Criterion A5, p. 161)
Separation anxiety disorder: “Developmentally inappropriate and excessive fear or anxiety…” (Criterion A, p. 190)

Ambiguous or unstated perspective Manic and hypomanic episodes: “inflated self-esteem or grandiosity” “distractibility… as reported or observed”; “Excessive involvement in
activities that have a high potential for painful consequences (e.g. engaging in unrestrained buying sprees, sexual indiscretions, or foolish
business investments)” (Criteria B1; B5, and B7, respectively, p. 124)
Major depressive episode & Major depressive disorder: “Depressed mood… as indicated by either subjective report… or observation by
others…”; “Markedly diminished interest or pleasure… as indicated by either subjective account or observation“; “Feelings of worthlessness
or excessive or inappropriate guilt…”; “Diminished ability to think or concentrate…either be subjective account or as observed by others”
(Criteria A1, A2, A7, and A8, respectively, p. 160–1)
Specific phobia & social anxiety disorder (social phobia): “The fear or anxiety is out of proportion to the actual danger posed by the specific
object or situation and to the sociocultural context”
All schizophrenia & psychotic disorders; Presence of hallucinations and/or delusions

Table 6
Symptom overlap across categories.

Specifier Diagnostic categories to which this specifier can be added

Anxious distress Bipolar and related disorders
Depressive disorders

Psychotic features Bipolar and related disorders
Depressive disorders
Schizophrenia spectrum and other psychotic disorders
Trauma and stressor related disorders
Neurocognitive disorders
Personality disorders

Rapid cycling Bipolar and related disorders
Mixed features Depressive episode

Bipolar and related disorders
Anxiety disorders

Panic attacks Any DSM-5 diagnosis
Catatonia Neurodevelopmental disorders

Psychotic disorders
Bipolar disorder
Major depressive disorder
Other medical conditions

K. Allsopp, et al. Psychiatry Research 279 (2019) 15–22

range of experiences captured by the same diagnostic labels. The ‘mixed
features’ specifier further blurs the boundary between depression and
bipolar diagnoses in that it can be added to episodes of depression
within the context of major depressive disorder where there are
symptoms of mania or hypomania present. Likewise, panic attacks can
be used as an adjunct to any DSM-5 diagnosis, and catatonia can be
specified across various diagnoses spanning several chapters (including
neurodevelopmental, psychotic, bipolar, and depressive disorder diag-
noses, and other medical conditions).

3.2.2. The role of trauma
The DSM-5 states at the outset the atheoretical nature of diagnostic

categories, however, one chapter of diagnoses is explicitly framed as
caused by or directly influenced by external factors; trauma- and
stressor-related disorders. The conceptualisation constructed by this
addition of causal information is a notable difference from the other
analysed chapters. For example, despite PTSD being described as a re-
sponse to an extreme traumatic stressor that would be distressing for
anyone to experience (“Exposure to actual or threatened death, serious
injury, or sexual violence…” criterion A, p. 271), in assigning the di-
agnosis the individual’s response is categorised as disordered. A related
dilemma can be seen in the remarkable semantic similarity between
various criteria for schizophrenia and PTSD diagnoses in DSM-5. These
include affective flattening and avolition, as well as hallucinations,
dissociative flashback episodes, restricted range of affect, and markedly
diminished interest or participation in significant activities. All of these
experiences would, in the presence of a traumatic event, be broadly
consistent with a diagnosis of PTSD. Furthermore, Table 7 illustrates
the diagnoses explicitly associated with trauma in DSM-5, and the DSM-
5 diagnoses that have been associated with childhood trauma or ad-
verse life experiences.

4. Discussion

As the DSM-5 acknowledges that experiences do not always fit
within the boundaries of a specific disorder, its rules are therefore in-
ternally inconsistent. The manual presents a classification of discrete,
homogeneous disorders, yet acknowledges that this structure cannot
always be followed due to the overlap between diagnostic categories.
Much of the heterogeneity identified in the above analysis is borne out
of pragmatic consideration for the application of the DSM-5 into clinical
practice. These allowances introduce flexibility for the clinician; giving
the possibility of categorising extraneous symptoms that do not fit
neatly within a diagnosis, or identifying experiences or behaviours as
distressing or disruptive for others despite not necessarily being dis-
tressing for the individual being assessed. Yet, this heterogeneous
flexibility has important consequences for the diagnostic classification’s
model of discrete disorders and the way cause is understood.

4.1. Theoretical implications: threats to the model of discrete disorders

The introduction of methods of clinical flexibility and

transdiagnostic clinical features, such as ‘anxious distress’ or ‘psychotic
features’, are contradictory to the DSM-5′s underpinning model of dis-
crete disorders. Within diagnostic criteria, the same diagnosis may be
applied in different ways by the clinician to suit individual situations
and presentations. Whilst clinically practical, such criteria introduce
heterogeneity and detract from the DSM-5′s presentation of diagnoses
as rigorously and consistently applied criteria that represent stable,
homogeneous disorders. In respect of these threats to the diagnostic
model whereby clinical utility is prioritised over theoretical con-
sistency, it would be more useful to adopt an assessment approach that
embraces this pragmatism, without simultaneously attempting to do
this within the confines of a strict diagnostic model.

4.2. Clinical implications: understanding cause

By making reference to trauma or stressors only in one dedicated
chapter, the DSM-5 implies that other diagnostic categories are un-
related to trauma. The consideration of social, psychological, or other
adversities within diagnoses is therefore minimised; symptoms are
constructed as anomalous or disordered, rather than potentially un-
derstandable in relation to a person’s life experiences. Even within the
trauma- and stressor-related disorders chapter, the experiences as-
sessed, despite being specifically linked with trauma, are seen as
symptomatic of a disordered or inappropriate response to that trauma.
The reverse of the implications of singling out one trauma-related
chapter is acknowledged by Spitzer and First; in their response to the
suggestion of clustering diagnostic categories by cause, they stated:

Most problematic is the characterization of the first cluster as pa-
tients with “brain disease.” Psychiatry has abandoned the reduc-
tionist “organic” vs “functional” distinction and now regards all
mental disorders as disorders of brain function. It would be a big
leap backward to delineate a subgroup of DSM disorders as invol-
ving “brain disease” with the implication that in other mental dis-
orders brain functioning is unimpaired (Spitzer and First, 2005, p.
1898).

By the same logic the same can be said of the role of trauma; for the
majority of the DSM-5 diagnostic categories, the criteria suggest to
clinicians that these difficulties are caused by the disorder (and im-
plicitly that these disorders are associated with brain function), and
may therefore limit exploration further than identification of the dis-
order. However, just as Wakefield (2013) describes how stressors other
than grief might also be related to experiences of low mood and de-
pression, accumulating evidence demonstrates that trauma or adversity
is involved in the development of many conditions and symptoms in-
cluding psychosis and bipolar disorder (Bentall et al., 2012; Palmier-
Claus et al., 2016; Varese et al., 2012). Clinical implications may in-
clude a focus on symptom reduction, on reducing those experiences
seen as inherently disordered, such as voice hearing, rather than on
removing only the distress associated with the experiences. In addition,
labelling distress as abnormal may in itself create further distress. For
example, flashbacks in the context of trauma are distressing in

Table 7
Relationship between DSM-5 diagnoses and trauma.

DSM-5 diagnoses with explicit mention of trauma DSM-5 diagnoses with associations with childhood adversities/ trauma, demonstrated through meta-analyses

Acute stress disorder Depression (Mandelli et al., 2015)
PTSD Anxiety (Lindert et al., 2013)
Adjustment disorders Obsessive compulsive disorder (OCD) (Miller and Brock, 2017)

Non-suicidal self-harm (Liu et al., 2016)
Functional neurological (conversion) disorders / medically unexplained symptoms (Ludwig et al., 2018)
Dissociation (Rafiq et al., 2018; Vonderlin et al., 2018)
Eating disorders (Molendijk et al., 2017)
Schizophrenia and psychotic disorders (Varese et al., 2012)
Bipolar disorder and related disorders (Palmier-Claus et al., 2016)

K. Allsopp, et al. Psychiatry Research 279 (2019) 15–22

themselves, but the diagnosis has the potential to make the experience
more distressing because the flashbacks are regarded as abnormal.

Furthermore, by obscuring heterogeneity within categories, psy-
chiatric diagnoses arguably obscure causal heterogeneity or other key
differences between individuals (Olbert et al., 2014). Evidence already
suggests that there may be distinct pathways in the development of
specific experiences identified within the diagnostic criteria of schizo-
phrenia, for example, strong associations between childhood sexual
abuse and hallucinations, compared with childhood neglect or in-
stitutionalisation and paranoia (Bentall et al., 2014). Likewise, in the
drive to create unique diagnostic entities by separating collections of
experiences from each other, potentially important similarities in the
experiences, or even processes, that exist across diagnoses may be lost.
An example of this may include similar causal mechanisms for voice-
hearing by individuals diagnosed with either bipolar disorder or schi-
zophrenia (e.g. Hammersley et al., 2003).

5. Conclusions

This analysis of chapters of the DSM-5 demonstrates that multiple
forms of heterogeneity are found across and within diagnostic cate-
gories. This heterogeneity has important implications for research,
clinical practice, and the provision of care that is specific to a person’s
individual needs. Pragmatic diagnostic criteria and idiosyncrasies offer
flexibility for psychiatrists to use ‘clinical judgement’, but they under-
mine the model of discrete categories of disorder. Yet the diagnostic
model still has implications for the way that cause is understood; lim-
ited reference to trauma implies that it affects only a limited number of
diagnoses, despite increasing evidence to the contrary. Furthermore, by
focusing on diagnostic categories, individual experiences of distress and
specific causal pathways may be obscured. A pragmatic approach to
psychiatric assessment, which allows for recognition of individual ex-
perience, may therefore be a more effective way of understanding
distress than maintaining a commitment to a disingenuous categorical
system.

Funding

This research was funded by University of Liverpool and Pearson
Clinical Assessment as part of a PhD scholarship.

Declarations of interest

Dr Allsopp reports grants from University of Liverpool and Pearson
Clinical Assessment during the conduct of the study.

Professor Read was employed by the University of Liverpool when
the work presented in this paper was undertaken. He is now employed
by the University of East London. He is on the Boards of the
International Society for Psychological and Social Approaches to
Psychosis (UK branch), the Hearing Voices Network – England, and the
International Institute for Psychiatric Drug Withdrawal, and is a
member of the Council for Evidence-based Psychiatry.

Professor Corcoran is employed by the University of Liverpool. She
is part funded by the National Institute of Health Research
Collaborative Leadership in Applied Health Research and Care North
West Coast (NIHR CLAHRC NWC). The views expressed are those of the
authors and not necessarily those of the NHS or NIHR. She also receives
funding from the Economic and Social Research Council and from
Mersey Care NHS Foundation Trust. She is a Trustee of the Liverpool
Mental Health Consortium

Professor Kinderman is employed by the University of Liverpool,
and has received funding from a number of research charities and
Councils. He is a former President of the British Psychological Society, a
member of the Council for Evidence-based Psychiatry and a trustee of
the Joanna Simpson Foundation. He is an honorary consultant clinical
psychologist with Mersey Care NHS Trust, and works occasionally for

the BBC.

CRediT authorship contribution statement

Kate Allsopp: Data curation, Formal analysis, Writing – original
draft. John Read: Writing – review & editing. Rhiannon Corcoran:
Writing – review & editing. Peter Kinderman: Writing – review &
editing.

Supplementary materials

Supplementary material associated with this article can be found, in
the online version, at doi:10.1016/j.psychres.2019.07.005.

References

American Psychiatric Association (APA), 2000. Diagnostic and Statistical Manual of
Mental Disorders: DSM-IV-TR®. American Psychiatric Association. https://doi.org/
10.1176/appi.books.9780890423349.

Bannister, D., 1968. The logical requirements o f research into schizophrenia. Br. J.
Psychiatry 114, 181–188.

Bentall, R.P., de Sousa, P., Varese, F., Wickham, S., Sitko, K., Haarmans, M., Read, J.,
2014. From adversity to psychosis: pathways and mechanisms from specific adver-
sities to specific symptoms. Soc. Psychiatry Psychiatr. Epidemiol. 49, 1011–1022.
https://doi.org/10.1007/s00127-014-0914-0.

Bentall, R P, Wickham, S., Shevlin, M., Varese, F., 2012. Do specific early-life adversities
lead to specific symptoms of psychosis? A study from the 2007 the adult psychiatric
morbidity survey. Schizophr. Bull 38, 734–740. https://doi.org/10.1093/schbul/
sbs049.

Braun, V., Clarke, V., 2006. Using thematic analysis in psychology. Qual. Res. Psychol. 3,
77–101. https://doi.org/10.1191/1478088706qp063oa.

Foucault, M., 1967. Madness and Civilization: A History of Insanity in the Age of Reason.
Pantheon Books, New York.

Galatzer-Levy, I.R., Bryant, R.A., 2013. 636,120 Ways to have posttraumatic stress dis-
order. Perspect. Psychol. Sci. 8, 651–662.

Hammersley, P., Dias, A., Todd, G., Bowen-jones, K.I.M., Reilly, B., Bentall, R.P., Jones,
B.-, 2003. Childhood trauma and hallucinations in bipolar affective disorder : pre-
liminary investigation childhood trauma and hallucinations in bipolar affective dis-
order : preliminary investigation 543–547. https://doi.org/10.1192/02-151.

Lindert, J., Von Ehrenstein, O.S., Grashow, R., Gilad, Gal, Braehler, E., Weisskopf, M.G.,
2013. Sexual and physical abuse in childhood is associated with depression and an-
xiety over the life course: systematic review and meta-analysis. Ó Swiss Sch. Public
Heal. https://doi.org/10.1007/s00038-013-0519-5.

Liu, R.T., Cheek, S.M., Nestor, B.A., 2016. Non-suicidal self-injury and life stress: a sys-
tematic meta-analysis and theoretical elaboration. Clin. Psychol. Rev. 47, 1–14.
https://doi.org/10.1016/j.cpr.2016.05.005.

Ludwig, L., Pasman, J.A., Nicholson, T., Aybek, S., David, A.S., Tuck, S., Kanaan, R.A.,
Roelofs, K., Carson, A., Stone, J., 2018. Stressful life events and maltreatment in
conversion (functional neurological) disorder: systematic review and meta-analysis of
case-control studies. Lancet Psychiatry 5, 307–320. https://doi.org/10.1016/S2215-
0366(18)30051-8.

Mandelli, L., Petrelli, C., Serretti, A., 2015. The role of specific early trauma in adult
depression: a meta-analysis of published literature. Childhood trauma and adult de-
pression. Eur. Psychiatry 30, 665–680. https://doi.org/10.1016/j.eurpsy.2015.04.
007.

McManus, S., Bebbington, P., Jenkins, R., Brugha, T., 2016. Mental Health and Wellbeing
in England: Adult Psychiatric Morbidity Survey 2014.

Miller, M.L., Brock, R.L., 2017. The effect of trauma on the severity of obsessive-com-
pulsive spectrum symptoms: a meta-analysis. J. Anxiety Disord. 47, 29–44. https://
doi.org/10.1016/J.JANXDIS.2017.02.005.

Molendijk, M.L., Hoek, H.W., Brewerton, T.D., Elzinga, B.M., 2017. Childhood mal-
treatment and eating disorder pathology: a systematic review and dose-response
meta-analysis. Psychol. Med. 47, 1402–1416. https://doi.org/10.1017/
S0033291716003561.

National Institute for Health and Care Excellence, 2005. Post-traumatic stress disorder:
mManagement. Author.

NICE, 2009. Depression in adults: recognition and management. Clin. Guidel [CG90].
Olbert, C.M., Gala, G.J., Tupler, L.A., 2014. Quantifying heterogeneity attributable to

polythetic diagnostic criteria: theoretical framework and empirical application. J.
Abnorm. Psychol. 123, 452–462.

Palmier-Claus, J.E., Berry, K., Bucci, S., Mansell, W., Varese, F., 2016. Relationship be-
tween childhood adversity and bipolar affective disorder: systematic review and
meta-analysis. Br J Psychiatry 209, 454–459. https://doi.org/10.1192/bjp.bp.115.
179655.

Rafiq, S., Campodonico, C., Varese, F., 2018. The relationship between childhood ad-
versities and dissociation in severe mental illness: a meta-analytic review. Acta
Psychiatr. Scand. 138, 509–525. https://doi.org/10.1111/acps.12969.

Read, J., Mayne, R., 2017. Understanding the long-term effects of childhood adversities:
beyond diagnosis and abuse. J. Child Adolesc. Trauma 10, 289–297. https://doi.org/
10.1007/s40653-017-0137-0.

Spitzer, R., First, M., 2005. Classification of psychiatric disorders. J. Am. Med. Assoc. 294,

K. Allsopp, et al. Psychiatry Research 279 (2019) 15–22

http://dx.doi.org/10.13039/100005622

http://dx.doi.org/10.13039/501100000707

https://doi.org/10.1016/j.psychres.2019.07.005

https://doi.org/10.1176/appi.books.9780890423349

http://refhub.elsevier.com/S0165-1781(19)30911-4/sbref0002

https://doi.org/10.1007/s00127-014-0914-0

https://doi.org/10.1093/schbul/sbs049

https://doi.org/10.1191/1478088706qp063oa

http://refhub.elsevier.com/S0165-1781(19)30911-4/sbref0006

http://refhub.elsevier.com/S0165-1781(19)30911-4/sbref0007

https://doi.org/10.1192/02-151

https://doi.org/10.1007/s00038-013-0519-5

https://doi.org/10.1016/j.cpr.2016.05.005

https://doi.org/10.1016/S2215-0366(18)30051-8

https://doi.org/10.1016/j.eurpsy.2015.04.007

http://refhub.elsevier.com/S0165-1781(19)30911-4/sbref0012

https://doi.org/10.1016/J.JANXDIS.2017.02.005

https://doi.org/10.1017/S0033291716003561

http://refhub.elsevier.com/S0165-1781(19)30911-4/sbref0015

http://refhub.elsevier.com/S0165-1781(19)30911-4/sbref0016

https://doi.org/10.1192/bjp.bp.115.179655

https://doi.org/10.1111/acps.12969

https://doi.org/10.1007/s40653-017-0137-0

http://refhub.elsevier.com/S0165-1781(19)30911-4/sbref0020

1898–1899.
Stansfeld, S., Clark, C., Bebbington, Paul, King, M., Jenkins, Rachel, Hinchliffe, S., 2016.

Chapter 2: common mental disorders. In: McManus, S., Bebbington, P., Jenkins, R.,
Brugha, T. (Eds.), Mental Health and Wellbeing in England: Adult Psychiatric
Morbidity Survey 2014. NHS Digital, Leeds.

Star, S.L., Lampland, M., 2009. Reckoning with standards. In: Lampland, M., Star, S.L.
(Eds.), Standards and Their Stories: How Quantifying, Classifying, and Formalizing
Practices Shape Everyday Life. Cornell University Press, Ithaca, NY, pp. 3–34.

Suchman, L., 1987. Plans and Situated Actions. Cambridge Univ. Press, pp. 224. https://
doi.org/10.1002/asi.20714.

Taylor, D., 2016. Prescribing according to diagnosis: how psychiatry is different. World
Psychiatry 15 224–22. https://doi.org/10.1002/wps.20342.

Varese, Filippo, Smeets, F., Drukker, M., Lieverse, R., Lataster, T., Viechtbauer, W., Read,
J., van Os, J., Bentall, R.P., 2012. Childhood adversities increase the risk of psychosis:
a meta-analysis of patient-control, prospective- and cross-sectional cohort studies.
Schizophr. Bull. 38, 661–671. https://doi.org/10.1093/schbul/sbs050.

Vonderlin, R., Kleindienst, N., Alpers, G.W., Bohus, M., Lyssenko, L., Schmahl, C., 2018.
Dissociation in victims of childhood abuse or neglect: a meta-analytic review.
Psychol. Med. 48, 2467–2476. https://doi.org/10.1017/S0033291718000740.

Wakefield, J.C., 2013. DSM-5: an overview of changes and controversies. Clin. Soc. Work
J. 41, 139–154. https://doi.org/10.1007/s10615-013-0445-2.

Young, G., Lareau, C., Pierre, B., 2014. One quintillion ways to have PTSD comorbidity:
recommendations for the disordered DSM-5. Psychol. Inj. Law 7, 61–74.

K. Allsopp, et al. Psychiatry Research 279 (2019) 15–22

http://refhub.elsevier.com/S0165-1781(19)30911-4/sbref0020

http://refhub.elsevier.com/S0165-1781(19)30911-4/sbref0021

http://refhub.elsevier.com/S0165-1781(19)30911-4/sbref0022

https://doi.org/10.1002/asi.20714

https://doi.org/10.1002/wps.20342

https://doi.org/10.1093/schbul/sbs050

https://doi.org/10.1017/S0033291718000740

https://doi.org/10.1007/s10615-013-0445-2

http://refhub.elsevier.com/S0165-1781(19)30911-4/sbref0028

Introduction

Method

Analysis

Findings

Heterogeneity within specific diagnostic criteria

The standards to which symptoms are compared

Comparisons with prior experience

Comparison with socially expected responses

No comparators

Duration of symptoms

Minimum duration

No duration

Discrete episodes

Identifiers of severity

Perspective from which distress is assessed

Wider heterogeneity across diagnostic categories

Symptom overlap across categories

The role of trauma

Discussion

Theoretical implications: threats to the model of discrete disorders

Clinical implications: understanding cause

Conclusions

Funding

Declarations of interest

CRediT authorship contribution statement

Supplementary materials

References

Expert paper writers are just a few clicks away

Place an order in 3 easy steps. Takes less than 5 mins.

Calculate the price of your order

Type of paper needed:

Pages:

You will get a personal manager and a discount.

Academic level:

We'll send you the first draft for approval by at

Total price:

$0.00