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Oxford Textbook of Psychopathology
 OX F O R D L I B R A RY O F P S YC H O LO G Y

Oxford Textbook of
Psychopathology
FOURTH EDITION

Edited by
Robert F. Krueger and Paul H. Blaney
Oxford University Press is a department of the University of Oxford. It furthers
the University’s objective of excellence in research, scholarship, and education
by publishing worldwide. Oxford is a registered trade mark of Oxford University
Press in the UK and certain other countries.

Published in the United States of America by Oxford University Press

198 Madison Avenue, New York, NY 10016, United States of America.

© Oxford University Press 2023

All rights reserved. No part of this publication may be reproduced, stored in

a retrieval system, or transmitted, in any form or by any means, without the
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above should be sent to the Rights Department, Oxford University Press, at the
address above.

You must not circulate this work in any other form

and you must impose this same condition on any acquirer.

Library of Congress Cataloging-in-Publication Data

Names: Krueger, Robert F., editor. | Blaney, Paul H., editor.
Title: Oxford textbook of psychopathology / [edited by] Robert F. Krueger, Paul H. Blaney.
Other titles: Textbook of psychopathology
Description: 4. | New York, NY : Oxford University Press, [2023] |
Includes bibliographical references and index. |
Identifiers: LCCN 2022040700 (print) | LCCN 2022040701 (ebook) |
ISBN 9780197542521 (hardback) | ISBN 9780197542545 (epub)
Subjects: MESH: Mental Disorders | Psychopathology
Classification: LCC RC454 (print) | LCC RC454 (ebook) | NLM WM 140 |
DDC 616.89—dc23/eng/20230124
LC record available at https://lccn.loc.gov/2022040700
LC ebook record available at https://lccn.loc.gov/2022040701

DOI: 10.1093/​med-​psych/​9780197542521.001.0001

Printed by Sheridan Books, Inc., United States of America

CONTENTS

Preface vii
About the Editors ix
Contributors xi

Part I • Foundations and Perspectives

1. Classification in Traditional Nosologies 3
Jared W. Keeley, Lisa Chung, and Christopher Kleva
2. Historical and Philosophical Considerations in Studying Psychopathology 33
Peter Zachar, Konrad Banicki, and Awais Aftab
3. The Hierarchical Taxonomy of Psychopathology 54
Christopher C. Conway and Grace N. Anderson
4. The Research Domain Criteria Project: Integrative Translation for
Psychopathology 78
Bruce N. Cuthbert, Gregory A. Miller, Charles Sanislow,
and Uma Vaidyanathan
5. Complex Systems Approaches to Psychopathology 103
Laura Bringmann, Marieke Helmich, Markus Eronen, and Manuel Voelkle
6. Developmental Psychopathology 123
Dante Cicchetti

Part II • Major Clinical Syndromes

7. Generalized Anxiety Disorder, Panic Disorder, Social Anxiety Disorder,
and Specific Phobia 147
Richard E. Zinbarg, Alexander L. Williams, Amanda M. Kramer,
and Madison R. Schmidt
8. Obsessive-​Compulsive and Related Disorders 181
Jonathan S. Abramowitz
9. Posttraumatic Stress Disorder and Dissociative Disorders 199
Richard J. McNally
10. Mania and Bipolar Spectrum Disorders 228
June Gruber, Victoria Cosgrove, Alyson Dodd, Sunny J. Dutra,
Stephen P. Hinshaw, Stevi G. Ibonie, Piyumi Nimna Kahawage,
Thomas D. Meyer, Greg Murray, Robin Nusslock, Kasey Stanton,
Cynthia M. Villanueva, and Eric A. Youngstrom
11. Depression: Social and Cognitive Aspects 257
Rick E. Ingram, Jessica Balderas, Kendall Khonle, and Joe Fulton
12. Diagnosis, Comorbidity, and Psychopathology of Substance-​Related Disorders 277
Ty Brumback and Sandra A. Brown
13. Substance Use and Substance Use Disorders 296
Kenneth J. Sher, W. E. Conlin, and R. O. Pihl
14. Schizophrenia: Presentation, Affect and Cognition, Pathophysiology and Etiology 332
Angus MacDonald III and Caroline Demro
15. Social Functioning and Schizophrenia 352
Jill M. Hooley and Stephanie N. DeCross
16. Paranoia and Paranoid Beliefs 380
Richard P. Bentall
17. Sexual Dysfunction 404
Cindy M. Meston, Bridget K. Freihart, and Amelia M. Stanton
18. Eating Disorders 424
Howard Steiger, Linda Booij, Annie St-​Hilaire, and Lea Thaler
19. Life-​Span and Multicultural Perspectives 450
Thomas M. Achenbach
20. Attention Deficit Hyperactivity Disorder 474
Siri Noordermeer and Jaap Oosterlaan
21. Autism Spectrum Disorders 492
Fred R. Volkmar and Kevin Pelphrey
22. Functional Somatic Symptoms 510
Peter Henningsen, Theo K. Bouman, and Constanze Hausteiner-​Wiehle
23. Sleep and Circadian Rhythm Disorders 523
Lampros Bisdounis, Simon D. Kyle, Kate E. A. Saunders, Elizabeth A. Hill,
and Colin A. Espie
24. Paraphilia, Gender Dysphoria, and Hypersexuality 549
James M. Cantor

Part III • Personality Disorders

25. The DSM-​5 Level of Personality Functioning Scale 579
Johannes Zimmermann, Christopher J. Hopwood, and Robert F. Krueger
26. The DSM-​5 Maladaptive Trait Model for Personality Disorders 604
Colin D. Freilich, Robert F. Krueger, Kelsey A. Hobbs, Christopher J. Hopwood,
and Johannes Zimmermann
27. Narcissistic Personality Disorder and Pathological Narcissism 628
Aaron L. Pincus
28. Borderline Personality Disorder: Contemporary Approaches to Conceptualization
and Etiology 650
Timothy J. Trull and Johanna Hepp
29. Schizotypy and Schizotypic Psychopathology: Theory, Evidence, and
Future Directions 678
Mark F. Lenzenweger
30. Psychopathy and Antisocial Personality Disorder 716
Christopher J. Patrick, Laura E. Drislane, Bridget M. Bertoldi, and Kelsey L. Lowman

Index 749

vi Contents
PREFACE

Although this Textbook may also serve active professionals by providing them with reviews
and updates, it is aimed primarily at graduate students taking an advanced survey course
in abnormal psychology and psychopathology. Among texts that might be used in such
courses, it has some distinctive aspects. It provides unusually thorough coverage of novel
and emerging approaches to studying psychopathology, including a focus on mod-
ern approaches to personality disorders. Throughout the volume, the focus is on what
is known about psychopathological constructs; while assessment and intervention are
sometimes mentioned, they are not covered systematically. Regarding traditional mental
disorder categories, we assume that, when studying this volume, the reader has DSM-​5
at hand and that systematic repetition of DSM-​5 criteria here would be an unwarranted
redundancy.
Scholars commonly use abbreviations (usually initializations) in place of their common
terms. Because it can be hard for a reader to keep track of their meanings, in this Textbook
brief glossaries of selected abbreviations have been added at the beginning of most chap-
ters. The reader should be alert with respect to the following abbreviations, as they are
defined differently in various chapters: AD, AS, ASPD, CD, ED, PD, PE, and SSD.
We have opted to forgo standard citation practice with respect to DSM and ICD
within chapters. The meaning of those abbreviations will likely be obvious to the reader,
but, as examples, we here note that DSM-​5 refers to the current edition of the Diagnostic
and Statistical Manual of Mental Disorder, published in 2013 by the American Psychiatric
Association, while ICD-​11 refers to the current version of the International Classification
of Diseases, effective in 2022 and published in 2019 by the World Health Organization.
As with the prior three editions of this Textbook, it is the product of an effort to enlist
the best possible array of experts and to charge those individuals with the task of summa-
rizing what future mental health professionals should know. Authors were given consider-
able latitude; as a result, the reader is exposed to a variety of outlooks and emphases when
moving from chapter to chapter. The roster of chapters shows some continuity from prior
editions but also important changes and innovations reflecting contemporary develop-
ments in the study of psychopathology. Changes reflect recent progress in the field plus (in
the case of returning authors) developments in these individuals’ thinking.

—​Robert F. Krueger
Minneapolis, Minnesota
—​Paul H. Blaney
Emory, Virginia
May 2022
A B O U T T H E E D I TO R S

Robert F. Krueger, PhD

Dr. Krueger is Distinguished McKnight University Professor in the Department of
Psychology at the University of Minnesota. He completed his undergraduate and gradu-
ate work at the University of Wisconsin, Madison, and his clinical internship at Brown
University. Professor Krueger’s major interests lie at the intersection of research on psycho-
pathology, personality, behavior genetics, health, and aging. He has received several major
awards, including the University of Minnesota McKnight Land-​Grant Professorship, the
American Psychological Association’s Award for Early Career Contributions, the Award
for Early Career Contributions from the International Society for the Study of Individual
Differences, and an American Psychological Foundation Theodore Millon Mid-​Career
Award. He is a Fellow of the American Psychopathological Association (APPA) and the
Association for Psychological Science (APS). He has been named a Clarivate Analytics
Highly Cited Researcher, and Research.com ranks him in the top 100 most impactful
psychologists in the world. He is also editor of the Journal of Personality Disorders.

Paul H. Blaney, PhD

Dr. Blaney received his BA degree from Eastern Nazarene College, Quincy,
Massachusetts, and his PhD in clinical psychology from the University of Minnesota. He
held faculty positions at the University of Texas at Austin, the University of Miami, and
Emory & Henry College, from which Dr. Blaney retired at the end of the 2013–​2014
academic year. He served on the editorial boards of a number of journals, including the
Journal of Abnormal Psychology and the Journal of Personality and Social Psychology. While
at the University of Miami, he was Associate Dean of the College of Arts and Sciences,
and, from 2000 to 2005, he was Dean of Faculty of Emory & Henry College.
 CO N T R I B U TO R S

Jonathan S. Abramowitz James M. Cantor

University of North Carolina at Chapel Hill Toronto Sexuality Centre
Chapel Hill, NC, USA Toronto, Canada
Thomas M. Achenbach Lisa Chung
University of Vermont Virginia Commonwealth University
Burlington, VT, USA Richmond, VA, USA
Awais Aftab Dante Cicchetti
Case Western Reserve University University of Minnesota
Cleveland, OH, USA Minneapolis, MN, USA
Grace N. Anderson W. E. Conlin
Fordham University University of Missouri
Bronx, NY, USA Columbia, MO, USA
Jessica Balderas Christopher C. Conway
University of Kansas Fordham University
Lawrence, KS, USA Bronx, NY, USA
Konrad Banicki Victoria Cosgrove
Jagiellonian University Stanford University
Kraków, Poland Stanford, CA, USA
Richard P. Bentall Bruce N. Cuthbert
University of Sheffield National Institute of Mental Health
Sheffield, UK Bethesda, MD, USA
Bridget M. Bertoldi Stephanie N. DeCross
Florida State University Harvard University
Tallahassee, FL, USA Cambridge, MA, USA
Lampros Bisdounis Caroline Demro
University of Oxford University of Minnesota
Oxford, UK Minneapolis, MN, USA
Linda Booij Alyson Dodd
McGill University Northumbria University
Montreal, QC, Canada Newcastle-​upon-​Tyne, UK
Theo K. Bouman Laura E. Drislane
University of Groningen Sam Houston State University
Groningen, The Netherlands Huntsville, TX, USA
Laura Bringmann Sunny J. Dutra
University of Groningen William James College
Groningen, The Netherlands Boston, MA, USA
Sandra A. Brown Markus Eronen
University of California University of Groningen
San Diego, CA, USA Groningen, The Netherlands
Ty Brumback Colin A. Espie
Northern Kentucky University University of Oxford
Highland Heights, KY, USA Oxford, UK
Bridget K. Freihart Kendall Khonle
University of Texas University of Kansas
Austin, TX, USA Lawrence, KS, USA
Colin D. Freilich Christopher Kleva
University of Minnesota Virginia Commonwealth University
Minneapolis, MN, USA Richmond, VA, USA
Joe Fulton Amanda M. Kramer
University of Kansas Northwestern University
Lawrence, KS, USA Evanston, IL, USA
June Gruber Robert F. Krueger
University of Colorado at Boulder University of Minnesota
Boulder, CO, USA Minneapolis, MN, USA
Constanze Hausteiner-​Wiehle Simon D. Kyle
Berufsgenossenschaftliche University of Oxford
Unfallklinik Murnau Oxford, UK
Murnau am Staffelsee, Germany Mark F. Lenzenweger
Marieke Helmich The State University of New York at
University of Groningen Binghamton
Groningen, The Netherlands Binghamton, NY
Peter Henningsen and
Technische Universität München Weill Cornell Medical College
Munich, Germany New York, NY, USA
Johanna Hepp Kelsey L. Lowman
Heidelberg University Florida State University
Mannheim, Germany Tallahassee, FL, USA
Elizabeth A. Hill Angus MacDonald III
University of Oxford University of Minnesota
Oxford, UK Minneapolis, MN, USA
Stephen P. Hinshaw Richard J. McNally
University of California Harvard University
Berkeley, CA, USA Cambridge, MA, USA
Kelsey A. Hobbs Cindy M. Meston
University of Minnesota University of Texas
Minneapolis, MN, USA Austin, TX, USA
Jill M. Hooley Thomas D. Meyer
Harvard University University of Texas
Cambridge, MA, USA Houston, TX, USA
Christopher J. Hopwood Gregory A. Miller
University of Zurich University of California at Los Angeles
Zurich, Switzerland Los Angeles, CA, USA
Stevi G. Ibonie Greg Murray
University of Colorado Swinburne University of Technology
Boulder, CO, USA Melbourne, Australia
Rick E. Ingram Siri Noordermeer
University of Kansas Vrije Universiteit
Lawrence, KS, USA Amsterdam, The Netherlands
Piyumi Nimna Kahawage Robin Nusslock
Swinburne University of Technology Northwestern University
Melbourne, Australia Evanston, IL, USA
Jared W. Keeley Jaap Oosterlaan
Virginia Commonwealth University Vrije Universiteit
Richmond, VA, USA Amsterdam, The Netherlands
and

xii Contributors
 Amsterdam UMC Annie St-​Hilaire
Amsterdam, The Netherlands McGill University
Christopher J. Patrick Montreal, QC, Canada
Florida State University Lea Thaler
Tallahassee, FL, USA McGill University
Kevin Pelphrey Montreal, QC, Canada
University of Virginia Timothy J. Trull
Charlottesville, VA, USA University of Missouri
R. O. Pihl Columbia, MO, USA
McGill University Uma Vaidyanathan
Montreal, QC, Canada Boehringer-​Ingelheim
Aaron L. Pincus Washington, DC, USA
Pennsylvania State University Cynthia M. Villanueva
University Park, PA, USA University of Colorado at Boulder
Charles Sanislow Boulder, CO, USA
Wesleyan University Manuel Voelkle
Middletown, CT, USA Humboldt-​Universität zu Berlin
Kate E. A. Saunders Berlin, Germany
University of Oxford Fred R. Volkmar
Oxford, UK Yale University
Madison R. Schmidt New Haven, CT, USA
Northwestern University Alexander L. Williams
Evanston, IL, USA Northwestern University
Kenneth J. Sher Evanston, IL, USA
University of Missouri Eric A. Youngstrom
Columbia, MO, USA University of North Carolina
Amelia M. Stanton Chapel Hill, NC, USA
University of Texas Peter Zachar
Austin, TX, USA Auburn University Montgomery
Kasey Stanton Montgomery, AL, USA
University of Wyoming Johannes Zimmermann
Laramie, WY, USA University of Kassel
Howard Steiger Kassel, Germany
McGill University Richard E. Zinbarg
Montreal, QC, Canada Northwestern University
Evanston, IL, USA

Contributors xiii
 PART
I
Foundations and
Perspectives
 CH A PT E R

1 Classification in Traditional Nosologies

Jared W. Keeley, Lisa Chung, and Christopher Kleva

Diagnosis is simple. The clinician meets with the have emerged, and enthusiasm for classifying men-
patient and assesses his or her symptoms in an inter- tal disorders has waxed and waned. During the last
view. Given the list of symptoms, the clinician then half of the twentieth century, classification was a
consults the current version of the DSM or ICD prominent theme in the study of psychopathology.
and decides which diagnoses are relevant. However, Following World War II and the foundation of the
like most things that appear to be simple, the topic United Nations, the World Health Organization
of classification becomes more complicated upon (WHO) took over responsibility for managing
examination. For example, even the name for this international health classification systems, resulting
topic is more complicated that many readers might in the sixth edition of the International Classification
think. In popular usage, terms like diagnosis, clas- of Diseases and Related Health Conditions (ICD)
sification, taxonomy, and nosology are often treated published in 1948, which including mental dis-
as if they either are synonyms or, at least, are largely orders for the first time. The release of the ICD-​6
interchangeable. However, to those who study this corresponded to the development of the first edi-
topic, these four terms have separable meanings. tion of the Diagnostic and Statistical Manual of
Diagnostic systems, generally called classifica- Mental Disorders (DSM) in the United States, first
tions, are lists of terms for conventionally accepted published in 1952, in recognition of a need for a
concepts that are used to describe psychopathology. unified system in the United States (Grob, 1991;
Classification, when the term is used specifically, refers Houts, 2000). Currently, DSM is in its fifth edition
to the activity of forming groups. Diagnosis, as this and the ICD is in its 11th edition.
word is used in medicine and the mental health field, This productivity has not, however, resolved
is the process by which individuals are assigned to some of the fundamental problems confronting
already existing groups. Taxonomy is a term usually psychiatric classification. Unresolved issues include
reserved for the study of how groups are formed. In the nature of the entities being classified, the defini-
effect, taxonomy is a meta-​level concept that looks at tion of what is a mental disorder, the nosological
different theoretical ways in which classifications can principles for organizing psychiatric classifications,
be organized, studied, and changed. Nosology is the
specific application of taxonomy (which can apply to
chemistry, zoology, or how to best arrange products in Abbreviations
the grocery store) in the context of medical sciences. AD autistic disorder
The classification of mental disorders has a AMPD alternative model of personality
lengthy history. The first description of a spe- disorders
cific syndrome is usually ascribed to an Egyptian ASD autism spectrum disorder
account of dementia dating to about 3000 bce. An CDD childhood disintegrative disorder
early classification of mental disorders was found in FFM five factor model
the Ayurveda, an ancient Indian system of medi- LAF low anxiety fearlessness
NOS not otherwise specified
cine (Menninger et al., 1963). Ancient Greek and
PCL-​R Psychopathy Checklist— ​Revised
Egyptian writings refer to disorders remarkably sim-
RDoC Research Domain Criteria
ilar to concepts of hysteria, paranoia, mania, and SCID Structured clinical interview for DSM  
melancholia. Since then, numerous classifications

3
the distinction between normality and pathology, of psychopathology allows clinicians to talk to each
and the validity of many diagnoses. Controversies other about the “things” in their world: the patients
exist regarding the definition and logical status of and clients who seek the care of mental health pro-
some diagnoses and even whether some entities fessionals. Without a classification system, clini-
are pathological conditions. For example, heated cians would be reduced to talking about clients one
debates occurred in the 1960s and 1970s over after another without any way of grouping these
whether homosexuality should be considered a clients into similar types. A classification allows the
mental disorder. Current debates exist on whether clinician to have a set of nouns that can be used to
Internet addiction belongs in an official classifica- provide an overview of the clinician’s world when
tion. Presently, there is no consensus regarding the talking to other clinicians, laypeople, insurance
taxonomic principles for resolving these controver- companies, or other professionals. Note that this
sies (Kamens et al., 2019). purpose provides a shorthand and does not imply
This chapter provides an overview of some issues or require any scientific reality to the concepts.
associated with the classification of psychopathol- Second, a classification structures information
ogy in traditional nosologies. The next chapter retrieval. Information in a science is organized
(“Historical and Philosophical Considerations in around its major concepts. Knowing a diagnostic
Studying Psychopathology”) will address modern concept helps the clinician to retrieve information
alternatives to the nosological approaches discussed about such matters as etiology, treatment, and prog-
in this chapter. In discussing these issues, the chap- nosis. A classification shapes the way information
ter presents an overview of psychiatric classification is organized thereby influencing all aspects of clini-
from a historical perspective so that the reader can cal practice and research. In the current world, in
understand how these issues have arisen and who which information is easily retrieved by electronic
have been the central authors involved in discus- searches on the Internet, classificatory concepts are
sions of these issues. useful devices by which professionals, family mem-
bers, clients, and interested laypeople can obtain
Purpose of Classification information about the prognosis, treatment, and
Classification involves creating and defin- current research related to various mental disorders.
ing the boundaries of concepts (Sartorius, 1990). Third, by providing a nomenclature to describe
Through this process, diagnostic entities are defined all levels of psychopathology, a classification estab-
(Kendell, 1975) and the boundaries of the disci- lishes the descriptive basis for a science of psycho-
pline are ultimately established. The reason that pathology. Most sciences have their origins in
psychiatric classification has had such an impact is description. Only when phenomena are systemati-
that it has defined the field of psychopathology. For cally organized is a science in the position to trans-
example, should Alzheimer’s disease, alcoholism, form accounts of individual cases into principles
or oppositional behavior in a child be considered and generalizations. Cases that are diagnosed with
mental disorders? Should they instead be considered a particular disorder should be similar in important
medical disorders or just problems of everyday liv- ways to other cases with that same diagnosis, and
ing? A classification of mental disorders stipulates these cases should be different in important ways
the range of problems to which mental health pro- from cases belonging to other diagnoses.
fessions lay claim. The fourth goal of classification, prediction, is
Classifications serve several purposes with spe- the most pragmatic from the perspective of clini-
cific goals. The goals of a good classification scheme cians. What a mental health professional typically
include (1) providing a nomenclature for practitio- wants from a diagnosis is information that is rel-
ners, (2) serving as a basis for organizing and retriev- evant to the most effective treatment and manage-
ing information, (3) describing the common patterns ment of his or her patient. A classification that is
of symptom presentation, (4) providing the basis for useful for prediction is a system in which there is
prediction, (5) forming the basis for the development strong evidence that patients with different diagno-
of theories, and (6) serving sociopolitical functions. ses respond differentially to a specific treatment or
The first major function of a classification is the one that informs how to best manage the nature of
provision of a standard nomenclature that facilitates that person’s condition. Classifications are also clini-
description and communication. A nomenclature is cally useful if the categories are associated with dif-
simply a list of names or terms within a classifica- ferent clinical courses even when the disorders are
tion system. At its most basic level, a classification not treated.

4 Foundations and Perspectives

 Fifth, by providing systematic descriptions of William Cullen, for example, applied Linnaeus’s
phenomena, a classification establishes the founda- principles for classifying species to illnesses. The
tions for the development of theories. In the natural result, published in 1769, was a complex struc-
sciences, especially biology and chemistry, a satis- ture involving classes, orders, genera, and spe-
factory classification was an important precursor cies of illness (cited by Kendell, 1990). One class
for theoretical progress (Hull, 1988). The system- was neurosis (Cullen introduced the concept as a
atic classification of species by Linnaeus stimulated general term for mental disorders) that was subdi-
important questions about the nature of phenom- vided into 4 orders, 27 genera, and more than 100
ena or processes that accounted for the system—​ species. Contemporaneous critics, who believed
questions that ultimately led to the theory of that there were far fewer diagnoses, dismissed
evolution. For these reasons, classification occupies Cullen as a “botanical nosologist” (Kendell, 1990).
a central role in research. For example, the National Nonetheless, interest in applying the principles of
Institute of Mental Health (NIMH) in the United biological classification to abnormal behavior con-
States has instituted a large-​scale project designed tinues today, as does the debate over the number of
to identify common pathological mechanisms that diagnoses. “Splitters” seek to divide mental disor-
could guide informed understanding of mental ders into increasingly narrowly defined categories,
disorders (termed the Research Domain Criteria whereas “lumpers” maintain that a few broadly
[RDoC] project; NIMH, 2012). The RDoC will be defined categories are adequate to represent psycho-
discussed at greater length in the next chapter as an pathology (Havens, 1985). One compromise is to
alternative to traditional classifications. create a hierarchical solution (again, similar to biol-
Finally, no classification system exists in a vac- ogy) in which there are a relatively small number
uum. Rather, a classificatory system exists in a con- of higher order groups divided into more specific
text of groups and individuals that stand to benefit varieties at lower levels of the hierarchy.
from the classification. For example, a classification The features used to classify mental disor-
of mental disorders can serve the social purpose of ders varied substantially across eighteenth-​and
identifying a subset of the population that society nineteenth-​century classifications. Some diagnoses
has deemed need treatment. However, the sociopo- were little more than single symptoms, whereas
litical functions of a classification are not always so others were broader descriptions resembling syn-
altruistic. The American Psychiatric Association, dromes. Yet other diagnoses were based on specu-
through its production of the various editions of the lative, early pre-​psychology theories about how the
DSM, has developed a lucrative printing business mind worked. As a result, many classifications from
that serves as a major funding source for the organi- the nineteenth century relied heavily on traditional
zation (Frances, 2014). At a more individual level, philosophical analyses of the faculties or attempted
some authors have argued that the classification of to organize disorders around poorly articulated
mental disorders serves the objective of maintaining views of etiology.
the social power of the majority by marginalizing
and stigmatizing those people who fall under the Kraepelin
domain of “mental illness” (e.g., Kirk & Kutchins, With the work of Emil Kraepelin, the structure of
1992; Kutchins & Kirk, 1997). modern classification began to take shape. Kraepelin
was born in 1856, the same year as Sigmund Freud,
History of Classification an ironic fact considering that they established two
Although attempts to classify psychopathology very different approaches to conceptualizing psy-
date to ancient times, our intent is to provide only chopathology. Kraepelin was influenced by two
a brief overview of major developments, especially traditions (Berrios & Hauser, 1988). The first was
those occurring in the past century, as a context for the scientific approach to medicine that dominated
understanding modern classifications. Examining German medical schools in the late nineteenth cen-
previous classifications shows that many current tury. Many important medical breakthroughs, espe-
issues have a long history. For example, writers in cially in bacteriology, occurred in Germany during
the eighteenth century, like many contemporary that period. German psychiatrists of the time gener-
authorities, believed that the biological sciences had ally believed that mental disorders were biological
solved the problems of classification and that bio- and that psychiatry would gradually be replaced by
logical taxonomies could serve as a model for clas- neurology. Kraepelin was also influenced by early
sifying psychopathology. The Edinburgh physician work in experimental psychology (Kahn, 1959).

Classification in Traditional Nosologies 5

During his medical training, he worked for a year International Statistical Classification of Diseases,
in the laboratory of Wilhelm Wundt (1832–​1920), Injuries, and Causes of Death, Sixth Revision (ICD-​
one of the first experimental psychologists. In early 6; World Health Organization, 1948). Because
research, Kraepelin applied Wundt’s methods to the it focused on all diseases, ICD-​6 added a section
study of mental disorders. devoted to mental disorders.
Kraepelin’s reputation was based on his text- The undertaking and consequent publication of
books of psychiatry. Like most textbook authors, the ICD-​6 by the WHO “marked the beginning
Kraepelin organized his volumes with chapters on of a new era in international vital and health sta-
each of the major groupings of mental disorders. tistics” (Reed et al., 2016). The WHO recognized
What has become known as Kraepelin’s classifica- the importance of agreed-​upon international rules
tions (Menninger et al., 1963) are little more than for mortality and morbidity data. An essential com-
the table of contents to the nine published editions ponent to ensure success was international coop-
of his textbooks. In the sixth edition, Kraepelin eration by other countries, recommending that
included two chapters that attracted consider- governments establish their own national commit-
able international attention. One chapter focused tees to collect vital and health statistics. The national
on the concept of dementia praecox (now called committees were to communicate with the WHO,
schizophrenia) which included hebephrenia, cata- which would serve as the central source and govern-
tonia, and paranoia as subtypes—​descriptions that ing body for international health statistics.
remained intact up through ICD-​10 and DSM-​IV Shortly after the publication of ICD-​6, the
but were removed in the current editions. The other American Psychiatric Association published its first
chapter discussed manic-​ depressive insanity—​ a official classification of mental disorders (DSM-​I;
revolutionary idea that combined mania and mel- American Psychiatric Association [APA], 1952).
ancholia, two concepts that had been considered The creation of this classification was justified
separate entities since the writings of Hippocrates. because there were four different classifications of
The two diagnoses, dementia praecox and manic-​ psychopathology in use in the United States during
depressive psychosis, established a fundamental dis- World War II, a situation that American psychiatry
tinction between psychotic and mood disorders that found embarrassing. Thus, the United States cre-
forms a linchpin of contemporary classifications. ated its own nomenclature that blended features of
the previous four systems (Grob, 1991).
The Early Editions of the DSM and ICD Generally, other countries in the world were
In medicine, the official classification of medi- like the United States in that, instead of adopting
cal disorders is the ICD, published by the WHO. ICD-​6 as the official system, most decided to use
Historically, this classification began at the end of locally created classificatory systems whose diagnos-
the nineteenth century when a group named the tic concepts did not have international acceptance.
International Statistical Institute commissioned Only five countries adopted the ICD-​6 classifica-
a committee headed by Jacques Bertillon (1851–​ tion of mental disorders: Finland, New Zealand,
1922) to generate a classification of causes of death. Peru, Thailand, and the United Kingdom. To
This classification, initially known as The Bertillon understand why, the WHO asked British psychia-
Classification of Causes of Death, was adopted as an trist Erwin Stengel to review the classifications of
official international classification of medical disor- mental disorders used in various countries. Stengel’s
ders at a meeting of 26 countries in France in 1900. review (1959) was very important because he care-
The name of the classification was slightly modified fully documented the widespread differences that
in the early 1900s to The International Classification existed in terminology from country to country
of Causes of Death. This original version of ICD was (and even within countries). Stengel concluded
revised at subsequent conferences held in 1909, that the variation in classifications from one coun-
1920, 1929, and 1938 (Reed et al., 2016). try to another meant there was a failure for these
After World War II, the WHO met to gener- systems to become useful nomenclatures. In addi-
ate a sixth revision of this classification. A decision tion, Stengel documented how different subsections
was made at that point to expand the classification of these classifications were organized according to
beyond causes of death and to include all diseases quite variable beliefs about the etiologies of the dis-
regardless of whether those diseases led to death or orders being classified. Stengel suggested that the
not (i.e., morbidity as well as mortality). The name solution was to develop a classification that simply
of the classification was revised accordingly to the provided operational definitions of mental disorders

6 Foundations and Perspectives

without reference to etiology. This suggestion led problems achieving high levels of agreement for any
to the eighth revision of the mental disorders sec- area of psychopathology. More modern commenta-
tion of ICD (World Health Organization, 1968), tors on this literature have suggested, however, that
which was to include a glossary defining the various the criticisms of diagnostic reliability during this era
components of psychopathology to go with the list were overstated (Kirk & Kutchins, 1992).
of diagnoses. Unfortunately, the glossary was not Concurrent with the empirical studies ques-
ultimately included. However, at the same time, tioning the reliability of psychiatric diagnosis, psy-
American psychiatrists did publish a second edition chiatry came under considerable attack from the
of DSM (i.e., DSM-​II; APA, 1968). DSM-​II, unlike antipsychiatry movement. Much of this criticism
ICD-​8, contained short prose definitions of the focused on the clinical activities of diagnosis and
basic categories in this system; however, the diag- classification. Szasz (1961) went so far as to argue
nostic terms and structure were otherwise almost that mental illness was a myth.
identical. By the late 1960s, three major criticisms of psy-
chiatric classification were popular. First, psychiat-
Criticisms of Classifications Through the 1960s ric diagnosis was widely thought to be unreliable.
During the 1950s and 1960s, concern about Second, classification and diagnosis were considered
the reliability of psychiatric diagnoses surfaced. fundamental components of the medical model that
Problems with levels of diagnostic agreement was questioned as the basis for understanding men-
had been noted in the 1930s. Masserman and tal disorders. This model clashed with other mod-
Carmichael (1938), for example, reported that els, particularly those stemming from behavioral
40% of diagnoses in a series of patients followed and humanistic perspectives that were influential
up 1 year later required major revision. Ash (1949) in clinical and counseling psychology. The medi-
compared the diagnoses of three psychiatrists who cal model of illness was viewed as both speculative
jointly interviewed 52 individuals applying to work and as demeaning of patients. Third, widespread
for the Central Intelligence Agency (CIA). These cli- concern was expressed, particularly among many
nicians agreed on the diagnosis for only 20% of the sociologists and psychologists, about the label-
applicants, and, in 30% of the cases, all three psy- ing and stigmatizing effects of psychiatric diagno-
chiatrists made a different diagnosis. Beck (1962) ses (Goffman, 1959, 1963; Scheff, 1966, 1975).
reviewed a series of reliability studies and reported Labeling theorists tended to view mental illness and
that the highest level of interclinician agreement other forms of deviant behavior as largely politically
was 42% for DSM-​I. The problem with reliability defined and reinforced by social factors and agen-
was further highlighted by the UK/​US Diagnostic cies. Psychiatric diagnoses were considered to be
Project, which found major differences in diagnos- self-​fulfilling prophecies in which patients adopted
tic practice between Britain and the United States the behaviors implied by the label. Their arguments
(Cooper et al., 1972; Kendell et al., 1971). These were bolstered by philosophers such as Foucault
studies suggested that Americans had an overinclu- (1988), who condemned psychiatry as little more
sive concept of schizophrenia and tended to apply than an agent of social control.
the diagnosis to any psychotic patient. British psy- A demonstration of these issues was contained in
chiatrists, in contrast, were more specific in the use a paper published in Science by Rosenhan (1973),
of schizophrenia as a diagnosis. These differences titled “On Being Sane in Insane Places.” In this
probably stemmed from both differences in the study, 8 normal persons sought admission to 12
definition of schizophrenia as well as its application different inpatient psychiatry units. All accurately
by individual psychiatrists. reported information about themselves except that
Diagnostic unreliability creates major problems they gave false names to avoid a mental hospital
for clinical practice and research. For example, the record, and they reported hearing an auditory hal-
results of studies on patients with schizophrenia as lucination in which a voice said “thud,” “empty,” or
diagnosed in Britain cannot generalize to patients “hollow.” In all instances, the pseudo-​patients were
diagnosed as having schizophrenia in the United admitted. Eleven of these admissions were diag-
States if these results are based on different appli- nosed as schizophrenia, the other as mania. On dis-
cations of the concept of schizophrenia. However, charge, which occurred on average 20 days later, all
the problem was not confined to schizophrenia. received the diagnosis of schizophrenia in remission.
The reliability studies of the 1960s and 1970s Rosenhan concluded that mental health profession-
were interpreted as indicating that clinicians had als were unable to distinguish between sanity and

Classification in Traditional Nosologies 7

insanity, an observation that was eagerly seized by the focused on superficial behavioral aspects of patients’
antipsychiatry movement. However, the Rosenhan lives (Havens, 1981). Klerman stressed the impor-
study was not without its critics. Rosenhan’s paper tance the neo-​Kraepelinians placed on improving
resulted in an explosion of responses that challenged the reliability and validity of diagnoses through the
his research and claimed that psychiatric diagnosing use of statistical techniques.
is a valid and meaningful process. The majority of Reading these propositions more than 50 years
the criticisms focused on Rosenhan’s flawed meth- later reveals the extent to which the neo-​Kraepelinians
odology and his unfounded interpretations that cli- felt the need to reaffirm the medical and biological
nicians are unable to distinguish between those who aspects of psychiatry. They felt embattled and sur-
are sane and those who are insane (Farber, 1975; rounded by powerful influences that advocated a
Millon, 1975; Spitzer, 1975; Weiner, 1975). very different approach. These propositions now
seem curiously dated, perhaps indicating the extent
The Neo-​Kraepelinians to which the neo-​Kraepelinian movement was suc-
During the 1970s, a small but effective group cessful in achieving its objectives. In many ways these
of researchers emerged in North American psy- propositions are now widely accepted within the
chiatry (Compton & Guze, 1995). These indi- profession, although most would probably express
viduals influenced both academic psychiatry and these positions less vehemently. Klerman’s state-
practice. The movement, usually referred to as ments also indicated the importance that the neo-​
the neo-​Kraepelinians (Klerman, 1978), sought to Kraepelinians placed on diagnosis and classification.
reaffirm psychiatry as a branch of medicine. The The way to ensure that their views were adopted was
neo-​Kraepelinians emphasized the importance of to develop a new classification system. The antipsy-
diagnosis and classification. The movement was a chiatry movement’s concerns about labeling and
reaction to the antipsychiatrists and the psycho- other negative reactions to psychiatric diagnosis pro-
analytic dominance of North American psychiatry. vided an important context that spawned DSM-​III
Klerman’s assumptions of the neo-​ Kraepelinian (APA, 1980), but the neo-​Kraepelinian movement
positions included emphasizing the medical roots provided the agenda (Rogler, 1997).
of psychiatry, such that psychiatry provides treat-
ment for people who are sick with mental illness. DSM-​III and Its Successors
Klerman further highlighted that the biological DSM-​III was the culmination of the neo-​
aspect of mental illness should be the central focus, Kraepelinian efforts to reestablish psychiatry as a
and any area of psychopathology that might repre- branch of medicine with diagnosis and classification
sent a disease process (e.g., schizophrenia) belonged as fundamental components. The classification took
to psychiatry, whereas other areas could be assigned more than 5 years of extensive committee work and
to ancillary professions such as psychology, social consultation to produce.
work, and nursing. The neo-​Kraepelinians, in the DSM-​III differed from DSM-​II in four major
attempt to medicalize psychiatric disorders, empha- ways. First, DSM-​III adopted more specific and
sized qualitative distinctions between normality and detailed diagnostic criteria, as compared to DSM-​
illness, a view criticized by writers such as Szasz, who II, in order to define the various categories of
considered mental disorders to be problems of liv- mental disorders. If a patient met the diagnos-
ing that are on a continuum with normal behavior. tic criteria, then the patient was said to belong to
Furthermore, the position of the neo-​Kraepelinians the category. Before DSM-​III, most definitions of
suggested different forms of disorders, which laid specific mental disorders were in prose format and
the basis for the continued use of a categorical implicitly referred to the “essence” of the disorder.
approach to classification. Since the publication of DSM-​III, the use of diag-
The neo-​Kraepelinians believed that psychiatry nostic criteria has reflected a shift to a prototype
should be founded on scientific knowledge. This model whereby a category is defined not by a list
assumption insisted on a solid empirical founda- of necessary and sufficient conditions but rather by
tion to ensure psychiatry as a medical specialty. The a list of characteristics that any individual member
neo-​Kraepelinians placed additional emphasis on may or may not have. Thus, two individuals may
diagnosis and classification by proposing that diag- qualify for the same diagnosis even though they
nosis is the basis for treatment decisions and clinical have few symptoms in common as long as each of
care—​a view that contrasted with that of psycho- them has enough of the listed symptoms to attain
analysts, who believed that descriptive classification the specified threshold. The more characteristics

8 Foundations and Perspectives

the individual evidences, the better fit that person Because of the revolutionary impact of DSM-​
is to the category (Cantor et al., 1980). The intent III, the mental disorders section of ICD-​10 (World
of using these diagnostic criteria was to make the Health Organization, 1992) was substantially
diagnostic process more explicit and clear-​cut, thus changed relative to earlier ICDs. ICD-​9, published
improving reliability. Second, DSM-​III proposed a in 1977, had been very similar to ICD-​8. Hence,
multiaxial system of classification. Thus, instead of ICD-​10 was published in two versions: a clinical
assigning one diagnosis per patient, as was typical version that contained prose descriptions of catego-
with DSM-​I and DSM-​II, clinicians were expected ries and a research version that contained diagnostic
to categorize the patients along five axes: (I) symp- criteria. However, ICD-​10 did not adopt a multi-
tom picture, (II) personality style, (III) medical axial system.
disorder, (IV) environmental stressors, and (V) As work was progressing on ICD-​10, a decision
role impairment. Third, DSM-​III substantially was made to perform another revision of DSM-​III
reorganized the hierarchical arrangement of men- that, it was hoped, would make it more similar to
tal disorder categories. In DSM-​I and DSM-​II, the ICD-​10. Indeed, a special “harmonization” com-
hierarchical system of organization recognized two mittee was established and work on the two manu-
fundamental dichotomies: (1) organic versus non- als proceeded, to some degree, in parallel. The result
organic disorders and (2) psychotic versus neurotic was DSM-​IV (APA, 1994). The committee work
disorders. DSM-​III dropped these dichotomies and that went into the creation of DSM-​IV was exten-
instead organized mental disorders under 17 major sive. The American Psychiatric Association even
headings based on the phenomenology of the disor- sponsored special research projects that attempted
der (e.g., “mood disorder” or “psychotic disorder”). to empirically resolve important debates that had
Fourth, DSM-​III was a much larger document than arisen around classificatory issues. One example of
its predecessors. DSM-​I contained 108 categories such a research project was the 1999 DSM Research
and was 130 pages in length. In contrast, DSM-​III Planning Conference sponsored by the American
had 256 categories and was 494 pages long. Psychiatric Association and the NIMH. This con-
By almost any standard, DSM-​III was an ference established the research priorities for future
astounding success. Financially, it sold very well. DSM editions, which included addressing the con-
As a result of this success, the American Psychiatric tinued dissatisfaction with the DSM nomenclature
Association developed a publication arm of the (Kupfer et al., 2002).
organization that began to publish a large number DSM-​IV was larger than previous DSMs in
of DSM-​related books and other psychiatric works. terms of the sheer size of its publication and the
Although explicitly an American classification, number of categories. Interestingly, different com-
DSM-​III quickly became popular in Europe, over- mentators have computed different numbers for
shadowing the ICD-​9 (1977), particularly among the total diagnoses in DSM-​IV, ranging from just
academics and researchers. under 300 to just under 400 (cf. Follette & Houts,
Another way of measuring the success of DSM-​ 1996; Kutchins & Kirk, 1997; Sarbin, 1997;
III is in terms of research. DSM-​III stimulated a Stone, 1997). Despite the intent of making DSM-​
great deal of research, especially regarding the defi- IV more like ICD-​10, DSM-​IV and ICD-​10 are
nitions of the categories proposed in this classifica- quite different. Of 176 diagnostic categories that
tion. As a result of this research, DSM-​III-​R (APA, shared similar names, there were intentional con-
1987) was published with the explicit goal of revis- ceptual differences in 21% (First, 2009). However,
ing the diagnostic criteria for the categories stem- there were unintentional nonconceptual differ-
ming from new research findings. However, like ences in 78% of categories; only one disorder—​
most committee products, the changes from DSM-​ transient tic disorder—​was identical between the
III to DSM-​III-​R were not limited to diagnostic cri- two systems (First, 2009). The most impactful dif-
teria. A number of new categories were introduced, ference between the two systems was the DSM-​IV
including a group of diagnoses associated with the “clinical significance” criterion, which required the
general category of “sleep disorders.” Additionally, presence of distress and/​or functional impairment
many specific categories were revised (e.g., histri- for diagnosis. ICD-​10 did not always consider the
onic personality disorder), dropped (e.g., attention presence of distress and/​or functional impairment
deficit disorder without hyperactivity), or added a requirement (Reed et al., 2016). Additionally,
(e.g., premenstrual syndrome had its name changed the ICD-​10 used diagnostic guidelines rather than
and was added to an appendix of DSM-​III-​R). criteria, which provided greater flexibility in their

Classification in Traditional Nosologies 9

interpretation and application than the DSM-​IV contrast, the number of categories with diagnostic
descriptions. criteria was reduced from 201 in DSM-​IV to 138
In 2000, the American Psychiatric Association in DSM-​5.
published a text revision of DSM-​IV, titled DSM-​ With respect to the development of the ICD-​11,
IV-​TR, which updated the prose sections of the the WHO focused on enhancing clinical utility and
manual but left the diagnostic criteria and num- global applicability (Reed, 2010). They were dedi-
ber of diagnoses mostly the same. Two exceptions cated to addressing the global mental health gap
included dropping the clinical significance criterion between those who need services and those who
from the tic disorders and adjusting it to account for receive them, and they sought to develop the ICD-​
nonconsenting victims of paraphilic disorders (First 11 as a mechanism for better identifying individu-
& Pincus, 2002). als with mental health needs. A three-​step plan was
The current editions of DSM and ICD have developed to provide guidance for the structure of
undergone yet another revision. DSM-​5 was pub- the Mental and Behavioral Disorders chapter in
lished in May 2013; ICD-​11 was approved in 2019. the ICD-​11. The first step involved evaluating the
The co-​chairs of DSM-​5 hoped to make DSM-​5 scientific evidence and information regarding the
as revolutionary as DSM-​III had been. The major actual use of the ICD in clinical practice, including
changes that they instituted with DSM-​5 were to two major surveys of psychiatrists and psychologists
add diagnostic spectra (e.g., the autism spectrum (Evans et al., 2013; Reed et al., 2011). The second
and the schizophrenia spectrum), offer dimensional step consisted of two field studies that examined
alternatives or enhancements to categorical diagno- how clinicians from around the world concep-
sis (e.g., the five dimensions for describing personal- tualize mental disorders and their relation to one
ity disorder in Section III titled “Emerging Measures another (Reed et al., 2013; Roberts et al., 2012).
and Models”), improve the assessment of dysfunc- These findings were used to inform the structure
tion as a result of psychopathology (the adop- (or table of contents) of the manual. The third step
tion of the WHO Disability Assessment Schedule involved two sets of field studies designed to evalu-
[WHODAS] in place of the Global Assessment of ate the proposed diagnostic guidelines (Keeley et al.,
Functioning [GAF], also in Section III), and drop 2016). One evaluated how global mental health cli-
the multiaxial approach to diagnosis that appeared nicians apply the guidelines to a set of case vignettes
in DSM-​III and DSM-​IV (all diagnoses are now in a with the intent of identifying confusions or clari-
single section of the manual instead of spread across fications. The other examined reliability and feasi-
five axes; APA, 2012a; 2013). bility in clinical settings. The development process
Just as DSM-​III was partially driven by the also involved an attempt to synchronize the ICD-​11
attempt to overcome the reliability issues with and DSM-​5. It is important to note that any differ-
DSM-​I and DSM-​II, one goal of DSM-​5 was to ences between the two systems were intentional. For
address meta-​structure issues that became promi- example, there are distinct differences in regards to
nent with DSM-​III-​R and DSM-​IV (Regier et al., sleep disorders and sexual health and gender iden-
2012). Specifically, the arrangement of disorders tity which ICD-​11 justifies as being more consistent
within the manual could be informed by empirical with current evidence and clinical practice (Reed et
findings rather than based solely on phenomeno- al., 2016).
logical similarity or work group arrangement. An
example is the dissolution of the childhood disor- Taxonomic Issues
ders grouping of DSM-​IV, whereby some disorders A number of controversies have arisen around
were placed under a neurodevelopmental heading the classification of psychopathology. The purpose
(e.g., intellectual disability, attention deficit hyper- of the following list is not to provide a compre-
activity disorder [ADHD], autism spectrum disor- hensive overview but simply to list the issues and
der) and others were placed with similar-​appearing controversies that are frequently raised about psy-
“adult” disorders (e.g., reactive attachment disorder chiatric classification.
in the trauma-​and stressor-​related disorders group).
In its final form, DSM-​5 contained 584 diag- Classification of Syndromes, Disorders,
nostic categories (compared to 357, by our count, or Diseases
in DSM-​IV). The size of DSM-​5 also grew to 947 The terms “syndrome,” “disorder,” and “dis-
pages from 886 pages in DSM-​IV while the pur- ease” can (erroneously) be used interchangeably to
chase cost of the manual more than doubled. In describe mental health conditions. In fact, these

10 Foundations and Perspectives

three terms refer to explicitly different assumptions asylum patients could be successfully (and simply)
about the nature of the category they describe. At treated and sent home. Many individuals believed
the most basic level of description, a person experi- that all other mental health conditions (especially
ences symptoms (self-​reported issues) and evidences schizophrenia) would follow similar developments,
signs (observed by others) of a problem. As men- eventually being “cured” once the proper cause was
tioned before, if mental health professionals were known. Unfortunately, no other conditions to date
forced to idiosyncratically describe the unique have enjoyed the scientific success of general paresis.
pattern of symptoms and signs for every patient, Rather, nearly all mental health categories are more
their work would be hopelessly stymied by trying properly termed “disorders,” in that their cause and
to account for each patient. However, symptoms therefore treatment are much more ambiguous.
and signs often co-​occur. When they co-​occur with
sufficient frequency, that condition is termed a syn- Classification of Disorders Versus Classification
drome. Note that the concept of a syndrome does of Individuals
not include any assumptions about the cause of the On the surface, this controversy appears to be
condition or why those symptoms belong together. a somewhat simple-​minded issue of terminology.
It is a purely descriptive notion. Individual patients are diagnosed with various
A disorder, on the other hand, provides an addi- mental disorders. A classification system contains
tional level of description beyond that of a syn- the names of mental disorders that have been rec-
drome. A disorder is a pattern of symptoms and ognized or are officially sanctioned as diagnoses by
signs that includes an implied impact on the func- some governing body. What difference does it make
tioning of the individual. While some causal factors whether a classification system is said to classify dis-
might be understood for a disorder, its etiology is orders or individuals?
still unclear or multiply determined. In contrast, a Interestingly, however, the authors of DSM-​
disease is a condition where the etiology is known, IV-​TR did think that this distinction made a dif-
and the path from the causal agent to the symptoms ference. They adopted an explicit position relative
and signs it causes is more or less clear. to this issue.
By way of example, a condition known as gen-
A common misconception is that a classification of
eral paresis was the most common single disorder
mental disorders classifies people, when actually what
represented in mental asylums in the mid to late
are being classified are disorders that people have. For
1800s. Initial investigations found that certain
this reason, the text of the DSM-​IV (as did the text of
individuals exhibited similar symptoms: grandiose
DSM-​III-​R) avoids the use of expressions such as “a
delusions and excitable behavior. At that point, the
schizophrenic” or “an alcoholic” and instead uses the
concept would properly be termed a syndrome.
more accurate, but admittedly more cumbersome,
After further investigation, it became clear that
“an individual with Schizophrenia” or “an individual
these individuals followed a similar course. The
with Alcohol Dependence.” (APA, 2000, p. xxxi)
problem began with excitable, grandiose behavior
but progressed to degenerative muscle movements, The DSM-​IV-​TR adopted this position to try
paralysis, and eventually death. Once the course to avoid the problem of stigma. Mental disorders
and outcome were known, general paresis was more largely refer to undesirable aspects of the human
properly termed a disorder. Many theories were pos- condition. Most of us do not want to be diagnosed
ited about the cause of the disorder, varying from with a mental disorder. To call someone “schizo-
overindulgence in alcohol to inflammation of the phrenic” is to imply that that individual is a mem-
meninges. However, eventually the discovery came ber of a diagnostic category that is immutable,
that it was tertiary syphilis, having migrated from unchanging, and destructive both to that person
a genital infection through a long dormant phase and to the significant others in that person’s life.
to the central nervous system. When general paresis The contrasting language of “an individual with
was understood as a syphilitic infection, the concept schizophrenia” implies that the person is not inher-
became a disease (Blashfield & Keeley, 2010). ently schizophrenic, but that schizophrenia, being
The history of general paresis is important in clas- a disease of the brain, is something that happens to
sification because it was a mental disorder that was people without the occurrence of the disease being
understood as a disease and eradicated with proper their fault. By saying that DSM is a classification of
treatment (i.e., penicillin). Paresis was a major vic- disorders, the authors were trying to emphasize the
tory for the science of psychiatry, as the majority of value of beneficence so that no or minimal harm

Classification in Traditional Nosologies 11

was done by assigning psychiatric diagnoses to indi- for action on the part of the person who has the
vidual human beings. condition, the medical or its allied professions,
On the other hand, as mentioned at the begin- and society.
ning of this chapter, diagnosis is the process of A mental disorder is a medical disorder whose
assigning individuals to categories. Individual clini- manifestations are primarily signs or symptoms
cians are concerned with the process of how best of a psychological (behavioral) nature, or if physical,
to characterize the individuals they see. The men- can be understood only using psychological
tal disorder groups characterized in a classification concepts. (p. 18)
would not exist without individuals who instanti-
Wakefield (1993) argued that Spitzer and
ated those symptoms. Admittedly, the population of
Endicott’s definition of a mental disorder failed
individuals with mental disorders is not permanent,
on many levels to successfully operationalize the
as many mental disorders are time limited (a per-
role of dysfunction inherent to mental disorders.
son initially does not have the disorder, then does,
Consequently, Wakefield (1992a, 1992b, 1993)
and goes back to not having it). The conditions that
provided an alternative definition of mental dis-
define the presence or absence of the disorder state
orders, in which he placed dysfunction within an
become crucial to understanding if the classification
evolutionary framework to better distinguish dis-
captures individuals, disorders, or both. Thus, the
orders from non-​ disorders. Wakefield’s approach
definition of mental disorder has profound conse-
to mental disorders, termed “harmful dysfunction,”
quences for what the classification captures.
considered mental disorders as “failures of internal
mechanisms to perform naturally selected func-
Definition of Mental Disorder
tions” resulting in impairment (Wakefield, 1999, p.
The definition of the domain to which a clas-
374). Wakefield appreciated the fact that defining
sification of mental disorders applies—​that is, all
a disorder must incorporate both value-​based (the
mental disorders—​is an important aspect of the
harm element) and scientific-​based (the dysfunction
classification. The early editions of the DSM and
element) criteria.
ICD did not provide any definition of a mental dis-
Wakefield and others have argued that both val-
order. An attempt to define this concept was pro-
ues and science are inherent components to the way
vided with DSM-​III by the head of the task force
in which DSM-​III and its successors have defined
that created this classification. Robert Spitzer’s view
individual mental disorders (see Sadler, 2005).
about how to define a mental disorder became con-
Distress, or harm, is included either by definition
troversial when he claimed “mental disorders are a
(feelings of depression, anxiety, etc.) or through
subset of medical disorders” (Spitzer et al., 1977,
the criterion of clinical significance. Clinical signifi-
p. 4). Many viewed this statement as an attempt
cance refers to the judgment made by the clinician
to secure exclusive rights to mental disorder treat-
that the severity of the dysfunction present in the
ment for psychiatry, thereby excluding or marginal-
disorder justifies treatment. Spitzer and Wakefield
izing other disciplines such as psychology and social
(1999) justified the inclusion of clinical significance
work. However, a psychologist on the DSM-​III task
in the DSMs as a means of limiting false-​positive
force, Millon (1983), stated that this sentiment
diagnoses (i.e., individuals who are symptomatic
was never the official perspective of those creating
but do not qualify for a full diagnosis of a disor-
DSM-​III.
der). Note, however, that clinical significance is not
One year later, Spitzer and Endicott (1978)
an objectively defined concept but rather requires
made an explicit attempt to define both mental dis-
a subjective decision by a clinician regarding when
order and medical disorder, with the former being
a set of symptoms warrants clinical attention. For
a subset of the latter. It is worth reproducing their
a classification system that has argued its strength
definitions in toto.
is objectivity and freedom from clinical bias, the
A medical disorder is a relatively distinct condition explicit inclusion of subjectivity in the definition of
resulting from an organismic dysfunction which a mental disorder is a problem.
in its fully developed or extreme form is directly Wakefield’s harmful dysfunction approach has
and intrinsically associated with distress, disability, not been without its critics. Lilienfeld and Marino
or certain other types of disadvantage. The (1995) criticized Wakefield’s evolutionary basis of
disadvantage may be of physical, perceptual, sexual, mental disorders, arguing that mental disorders do
or interpersonal nature. Implicitly there is a call not have defined properties and are not necessarily

12 Foundations and Perspectives

evolutionary dysfunctions. To use a medical exam- was performed by a priest and psychiatrist named
ple, sickle-​cell anemia is evolutionarily functional in Thomas Moore. Moore (1930) gathered data on
malaria-​prone regions but typically dysfunctional in individuals with schizophrenia and subjected his
malaria-​free environments. Similar arguments can descriptive information to a factor analysis. The
be made with specific phobias, such as snake pho- result was five factors, which, in retrospect, were
bias, which could be quite functional when an indi- quite contemporary in their meaning. Using modern
vidual human lives near poisonous snakes; however, terms, these five factors could be named as follows:
a snake phobia is of less functional use for the typi-
cal person living in a large city in which snakes are 1. Positive symptoms of schizophrenia
uncommon. Other critics (Fulford, 1999; Richters 2. Negative symptoms of schizophrenia
& Cicchetti, 1993; Sadler & Agich, 1995) have 3. Manic symptoms
provided analyses and substitutes to Wakefield’s 4. Depressive symptoms
harmful dysfunction concept. For further discus- 5. Symptoms of cognitive decline (dementia)
sion on the debate centered on Wakefield’s harm-
ful dysfunction approach, we refer the reader to a Shortly after World War II, Eysenck (1947),
recent review about how the debate is related to the a psychologist in Great Britain, became a strong
DSM-​5 (Wakefield, 2016). advocate for a dimensional approach to all psycho-
As mentioned briefly in the beginning of this pathology. He argued for three basic dimensions
chapter, lack of a consensual definition of mental (Eysenck & Eysenck, 1976) that could be used to
disorders has important consequences. Definitions organize all descriptive information about mental
establish boundaries, in this case the boundary disorders, which he called:
regarding what is and what is not a mental disor-
der and hence the boundaries of the mental health 1. Neuroticism
profession. The current definition posed in DSM-​5 2. Extroversion
reflects the logic of Wakefield’s harmful dysfunction 3. Psychoticism
concept but is more lenient regarding the cause of
the dysfunction. Furthermore, the DSM-​5 defini- He used neuroticism to refer to individuals who
tion included the phrase “clinically significant dis- were anxious or prone to negative feelings ver-
turbance,” but the definition did not clarify the sus those who were emotionally calm and steady.
meaning of this phrase (APA, 2013, p. 20). The Extroversion referred to an individual’s proneness to
WHODAS, in Section III, was included to give be outgoing versus introverted. His description of
clinicians more precision in the measurement of psychoticism included a variety of other constructs,
dysfunction. including constraint, impulsivity, sensation-​seeking,
and even creativity. Eysenck believed that high lev-
Dimensions Versus Categories els of the personality trait psychoticism made one
Although the term “classification” traditionally prone to schizophrenia or other psychotic disorders.
applies to a system of classes or categories, a number These three dimensions have resurfaced in one form
of contemporary writers have suggested that dimen- or another in many later models, although the same
sional approaches to the classification of psychopa- names are sometimes applied to slightly different
thology would be preferable (Widiger & Samuel, constructs.
2005; Widiger et al., 2005). Eysenck was a protégé of Aubrey Lewis, a lead-
The debate about categorical versus dimensional ing British psychiatrist of his time. Later Lewis and
models is an old one. Advocates for each model Eysenck split over Eysenck’s determined advocacy of
tended to adopt particular theoretical and statistical a dimensional model. Lewis, a physician, believed
approaches. Advocates of a dimensional model were that a categorical/​disease model of psychopathol-
often users of factor analysis, whereby advocates of ogy was more appropriate. Shortly after this split
a categorical model favored cluster analysis. Factor between Eysenck and Lewis in the late 1950s, a
analysis is a multivariate statistical procedure pio- related debate appeared in the British literature
neered in the 1930s by L. L. Thurstone (1934) and about whether depression was best viewed from a
his colleagues. dimensional perspective or from a categorical model
The first known application of a dimensional (Kendell, 1968; see Klein, 2010, for a modern dis-
approach to the classification of psychopathology cussion of this issue).

Classification in Traditional Nosologies 13

 After Eysenck, other dimensional models of psy- Clark (2007) expressed concern about the
chopathology began to appear. Within child psy- application of the FFM to personality disorders
chopathology, Achenbach (1966, 1995) became a because the most commonly used measure of the
proponent of a dimensional model with two con- FFM, known as the NEO-​PI-​R, was designed to
structs: (1) an internalizing dimension and (2) an measure normal-​ range personality. For example,
externalizing dimension. Internalizing referred to the construct of openness, as measured in normal-​
children who displayed internally expressed emo- range personality, does not seem to be meaningfully
tional problems, like anxiety or depression, whereas related to pathology, but a separate construct—​
externalizing referred to children who acted out oddity—​ does capture behaviors of interest like
through disruptive behavior. More recently, Krueger magical or obsessive thinking (Watson et al., 2008).
(1999; Krueger et al., 2005; Forbes et al., 2016) Cicero et al. (2019) investigated how symptoms of
has shown that this two-​dimensional approach can schizophrenia and schizotypal traits align with the
be generalized to account for a subset of common personality taxonomy, finding that positive symp-
DSM diagnoses. Additionally, Eaton et al. (2012) toms were linked to psychoticism while negative
replicated the internalizing-​externalizing structural symptoms linked to extraversion. Recent work has
model which was found to be applicable to both compared the domain overlap between common
men and women. Under that context, generalized personality measures (Crego et al., 2018) and the
anxiety disorder, major depressive disorder, and large degree of overlap between normal and abnor-
other anxiety disorders loaded onto a common fac- mal personality presentations with respect to psy-
tor, while antisocial personality disorder and sub- chopathology (Widiger & Crego, 2019).
stance use disorders loaded onto a second factor. Many models of normal and disordered person-
However, that organization left many facets of psy- ality were considered by the DSM-​5 work group
chopathology unaccounted for (e.g., bipolar disor- concerned with personality disorders. In the end,
ders, psychotic disorders). Later work investigated a the work group developed its own distillation of
wider range of disorders and found a more compli- these models that—​ when empirically tested—​
cated structure, but the dimensions of internalizing largely resembled the domains of the FFM (Krueger
and externalizing remained (Conway et al., 2020; et al., 2012). Through an iterative process, they
Kotov et al., 2017). Studies of this kind formed the refined a list of 37 initial personality facets into a
basis of the meta-​structure of the DSM-​5 and, to best-​fitting model that contains 25 facets loading
a lesser degree, ICD-​11. Note that these structures onto five higher-​ order domains (negative affect,
are often hierarchical in nature, with higher-​order detachment, antagonism, disinhibition, and psy-
factors corresponding to more general domains and choticism). While the structure resembles the FFM,
lower-​order factors referring to more specific mani- it was intended to represent the more extreme and/​
festations. Similar to our earlier mention of lump- or pathological variants of those traits (Krueger et
ers and splitters, some advocates prefer description al., 2012).
at the broader, higher level while others are more The ICD-​11 approach to classifying personality
focused on the lower, narrower descriptors. disorder also moved toward a dimensional model,
Another subset of psychopathology that has been although it looks somewhat different from the
a focus of dimensional investigation is the personal- DSM-​5 proposal (Tyrer et al., 2015). First, personal-
ity disorders. A variety of investigators such as James ity disorder is classified along a severity continuum,
McKeen Cattell (1860–​1944), Joy Paul Guilford moving from severe to moderate to mild personality
(1897–​1987), and Lewis Goldberg (1932–​) devel- disorder, with an option to indicate a subthreshold
oped dimensional approaches to personality traits personality difficulty that is not severe or impair-
in normal human beings. McCrae and Costa (1990) ing enough to warrant a clinical diagnosis. Next,
expanded this earlier research into what has become one may indicate the presence or absence of each
known as the Five-​Factor Model (FFM) of person- of five personality trait domains (negative affectiv-
ality with five dimensions: ity, dissocial, disinhibition, anankastic, and detach-
ment). Four of those domains overlap substantially
1. Neuroticism with similar personality concepts in the DSM-​5
2. Extroversion model (negative affectivity, dissocial, disinhibition,
3. Agreeableness and detachment); however, the ICD-​11 does not
4. Openness include a psychoticism domain. In the ICD tradi-
5. Conscientiousness tion, schizotypal presentations are conceptualized as

14 Foundations and Perspectives

a psychotic disorder and not a personality disorder. everyday life, categorical concepts are used because
Instead, the ICD-​11 includes the domain of anan- they are familiar and easy. Psychiatrists have been
kastic features, which is characterized by rigidity, trained in a tradition associated with medical and
perfectionism, and overregulation of one’s own and biological classification, and this influence has col-
other’s behavior. ored mental health classification. Both biological
Although statistical work on the categorical and medical classificatory systems are categorical;
approach to the classification of psychopathology however, in regard to medical classification, cer-
has not been as extensive, a number of studies have tain portions can be viewed as dimensional (e.g.,
appeared. The most notable of these efforts were hypertension).
Maurice Lorr’s use of cluster analysis to study indi- The tendency to think categorically should not
viduals with schizophrenia (Lorr, 1966) and Paul be underestimated. Work in anthropology suggests
Meehl’s development of taxometrics—​a set of tech- that hierarchically organized categorical systems are
niques aimed at discerning the latent categorical vs. the product of universal cognitive mechanisms that
dimensional status of specific psychopathological have evolved as adaptive ways of managing informa-
constructs (Meehl, 1995; cf. Schmidt et al., 2004). tion (Atran, 1990; Berlin, 1992). In his study of var-
Interestingly, the majority of taxometric studies ious indigenous cultures, Berlin (1992) found that
have supported dimensional structures for mental these societies had hierarchical organizations for the
disorders rather than categorical, although some living things they encounter in their environment,
have favored distinct groups of disordered individu- and the structure of these “folk taxonomies” tended
als (Haslam et al., 2012, 2020). An analysis that to be universal—​but not concordant with scientific
parallels the logic of factor analysis but is used to classifications. Evidence from cognitive and devel-
identify categories is called latent class analysis (for a opmental psychologists shows that children seem
single indicator variable) or latent profile analysis (for to learn about the natural world through category
multiple indicator variables). In essence, the analysis formation (Hatano & Inagaki, 1994; Hickling &
helps the investigator identify the number of pos- Gelman, 1995; Kalish, 2007; Nguyen, 2008). It is
sible groups that exist in a sample of individuals. A not surprising, therefore, that people, including cli-
relevant example is the debate surrounding whether nicians, prefer to use concepts that are the products
posttraumatic stress disorder (PTSD) is best repre- of these cognitive mechanisms that favor categorical
sented by a single group—​and single diagnosis—​ concepts (Gelman, 2003; Yoon, 2009).
differentiated only on severity or multiple groups There are, however, substantial disadvantages to
that differ in symptom type. The DSM-​5 elected using categories. Categorical diagnoses often result
to expand the symptoms of PTSD to incorporate a in the loss of some information. Categorical systems
wider range of presentations within a single diagno- also depend on nonarbitrary boundaries or at least
sis, whereas the ICD-​11 opted to split the diagno- on points of rarity between syndromes, as are seen
sis of PTSD into two: regular PTSD and complex in the valley between the two modes in a bimodal
PTSD (Elklit et al., 2013; Wolf et al., 2015). frequency histogram (Kendell, 1975, 1989).
A new analysis approach termed factor mixture Haslam (2002) outlined a taxonomy of “kinds
analysis (Muthen, 2006; Muthen & Muthen, 2010) of kinds,” or a model of category types ranging
creates hybrid dimensional-​ categorical models, from true categories to true dimensions. The truest
where the taxonicity and dimensionality of a set of form of a category is what various philosophers have
measures can be examined simultaneously. This sort termed a “natural kind” (Kripke, 1980; Putnam,
of model would represent distinct groups of indi- 1982). A natural kind represents a group with a
viduals (taxa) that vary along some latent dimen- unitary etiology that leads to necessary outcomes
sion (i.e., an ordering of the groups). Interestingly, and a discrete separation from other psychopatho-
when this sort of hybrid model is employed, some logic syndromes. However, true natural kinds are
studies find that dimensional structures continue rare or nonexistent in the realm of psychopathology
to be favored (Eaton et al., 2011, 2013; Wright et (Zachar, 2000). It could be that certain groups are
al., 2013), whereas others find taxons meaningfully qualitatively separate from other entities but lack
differentiated by underlying dimensions (Bernstein the underlying “essence” of a natural kind, which
et al., 2010; Lenzenweger et al.,2008; Picardi et Haslam termed “discrete kinds.” An example would
al., 2012). be the qualitative difference between regular and
Most classifications of psychopathology employ endogenous depression proposed by some (van Loo
categories because they offer certain advantages. In et al., 2012). Even though depression exists on a

Classification in Traditional Nosologies 15

severity dimension, these authors would claim that for multiple personality disorders and for them to
a qualitative shift occurs at a certain threshold, cre- present differently than another person diagnosed
ating a truly different kind. However, categories of with the same disorder. In fact, many individuals
mental disorders are not always well demarcated. do not fall neatly into an arranged category, which
When a category does not have a clear boundary, has led personality disorder-​not otherwise specified
Haslam terms it a “fuzzy kind.” A fuzzy kind exists (PD-​NOS) to be the most frequently diagnosed
when there is a definable group, but the character- personality disorder. The work group proposed
istics of that group blend into other groups. Next, an empirically supported, hybrid model, termed
there are phenomena, such as hypertension, that the Alternative Model of Personality Disorders
can be thought of existing along a dimension (mea- (AMPD), whereby some personality disorder cat-
sured by blood pressure), but for which there are egories would be retained while also including a
functional reasons to categorically scale the dimen- dimensional model to describe individuals who
sion (i.e., a cut point above which the person is seen did not fit neatly into a category (Skodol, 2012).
as needing medical intervention). The choice of the Additionally, the proposed model mirrored the
cut point may be debatable, but the presence of a popular FFM of personality by mapping patho-
cut point serves a pragmatic purpose. These sorts logical variants of the Big Five personality factors
of groups are termed “practical kinds” (Haslam, onto personality disorders as well as the lower-​order
2002; Zachar, 2000). The final entry in Haslam’s personality facets. The creators of the AMPD con-
taxonomy consists of true dimensions, or continua ceptualized personality disorders as a result of the
of psychological characteristics that do not justify interaction of personality functioning impairment
any cut point. and pathological personality traits. Within the work
From this discussion, the selection of the type group, there was not unanimous agreement on the
of theoretical concept to use in classification (i.e., best approach involving dimensions and/​ or cat-
dimensions vs. categories) is fundamental to the egories (Zachar et al., 2016). This hybrid structure
development of a classification. Jaspers (1963) sug- was a compromise that could capitalize on the ben-
gested that different classificatory models might be efits of both categories and dimensions. However,
required for different forms of psychopathology. the Board of Trustees of the American Psychiatric
This idea has merit. Some conditions, especially Association did not accept the proposal, electing to
those traditionally described as organic disorders, keep the same 10 categorical personality disorders
are similar to diagnoses in physical medicine. found in DSM-​IV. Instead, the work group pro-
These could probably best be represented using a posal was published as a separate chapter in Section
categorical model in which diagnoses are specified III of the manual to foster further research, with the
by diagnostic criteria. Other areas of psychopathol- hope of adopting those portions of the model that
ogy, especially the affective disorders and personal- achieve sufficient empirical support.
ity disorders, might be better represented using a
dimensional framework. However, the distinction Atheoretical Approach to Classification
between categories and dimensions is a human At the times that DSM-​I and DSM-​II were
convenience that we force on the world. A better written, the dominant theory in psychiatry was
approach might be to think about how categories psychoanalysis (Blashfield et al., 2014; Cooper &
and dimensions can best be used to describe a given Blashfield, 2016). However, as the psychoanalytic
psychopathological phenomenon and how they perspective began to lose favor, a more biologi-
each might be better for individual purposes, such cal approach began to emerge as the force behind
as clinical diagnosis versus research. explaining and conceptualizing mental disorders.
Interestingly, the issue of dimensions versus cat- The committee members of DSM-​III (headed by
egories became a focus of significant controversy Spitzer) were sensitive to this division between the
within DSM-​5. The Personality and Personality psychoanalytic and biological explanations of men-
Disorders Work Group for DSM-​5 was orchestrated tal disorders. Consequently, the determination was
in hopes of offering an alternative model that would made that DSM-​III would be theory-​ neutral in
address the shortcomings of the DSM-​IV (Morey order for the classification to be more accessible to
et al., 2015; Zachar et al., 2016). The categorical all mental health professionals. This approach has
model led to a significant level of co-​occurrences been preserved throughout the modern DSMs and
and heterogeneity among personality disorders. It is mirrored in the ICD but has sparked a number
fairly common for an individual to meet the criteria of criticisms on the failure of specifying a theory

16 Foundations and Perspectives

to guide the classification system (Castiglioni & ICD have notoriously ignored pathological processes
Laudisa, 2014; Harkness et al., 2014). Most writ- that exist among individuals, like family systems or
ers who have thought about the recent classification romantic partners, and a group of researchers have
systems agree that the implicit theoretical model been petitioning to include diagnoses of relational
associated with these systems is the biological (med- processes for decades (Wambolt et al., 2015). For
ical) approach (Harkness et al., 2014; Sedler, 2016). example, a married couple might be highly dys-
According to Harkness, Reynolds, and Lilienfeld functional even though neither individual qualifies
(2014), the refusal by the authors of these classi- for an individual mental health disorder. Another
fications to postulate a theory of psychopathology example of the effect of focusing on individualism
explicitly hinders scientific progress within the field as a value can be seen with the removal of gender
and removes focus from the evolved adaptive sys- identity disorder as a mental disorder. Nonbinary,
tems which underlie pathology. gender fluid, or non-​cisgender identities should not
Though the authors of DSM-​III denied having be classified as mental disorders because the strug-
a theory, Sadler (2005) argued that certain values gles associated with such identities are induced by
or assumptions are nonetheless embedded in the society and not something inherent within the indi-
structure of the DSMs and ICDs that emerge with vidual (Drescher et al., 2012).
their application. Because these six values, as dis- Fourth, psychiatric disorders are assumed
cussed by Sadler, do represent the beginning of a to have a natural essence. In other words, disor-
theory of psychopathology, each of them will be ders follow a natural order whereby etiologies are
discussed next. multifactorial—​ including biological, psychologi-
The first is the value of empiricism, which is the cal, and sociocultural influences. Sadler stated that
belief that the contents of psychiatric classification this assumption is important to understanding
are based on scientific research, complete with test- the atheoretical approach of these classifications
able hypotheses and controlled clinical trials. This because they stipulate that multiple theories, not
empirical advancement discourages the exclusive just one all-​encompassing explanation, are essen-
use of expert opinions and clinical judgment when tial to understanding mental disorders. According
making nosological decisions, as was seen in early to Bueter (2019), the inherent pluralism of this
editions of the DSM and ICD. approach allows the classifications to fill a mul-
Second, Sadler discussed how the classification titude of roles expected of them. Because the
is hypo-​narrative, a term he coined to describe the classifications—​which possess influence and a spe-
manuals’ lack of storytelling qualities. Narrativity cial power over public perception of mental health
was especially lost during the transition from DSM-​ due to their required use in many contexts, such as
II to DSM-​III, when disorder descriptions became healthcare reimbursement or research funding—​
symptom listings. Applying this language to diag- are often expected to fit a one-​size-​fits-​all purpose,
nosing an individual loses the richness of the “bio- a pluralistic nature allows them to fit a variety of
graphical” explanation of the individual. However, contexts and has many advantages for describing
Sadler argued that the role of classifications is not the breadth of psychopathology. With its tenth
to capture necessarily the life story of each patient edition, the ICD attempted to directly address the
but to address the signs and symptoms associated one-​size-​fits-​all problem by publishing several ver-
with diagnosis. Hypo-​ narrativity leads the clini- sions of the classification: one for clinical use, one
cian to focus exclusively on the symptoms of a for research, and one specifically for use in primary
patient, rather than on the interactions between care. Regardless, this pluralistic approach impedes
the symptoms and the relationships, priorities, aspi- monistic beliefs that a single theory (like evolution
rations, and daily functioning of the patient. It is in biology) could account for the entire landscape,
these interactions that provide the plot line for the as might be the agenda of biologically oriented
patient’s story. researchers (Bueter, 2019).
A third assumption of modern classifications is The fifth value, pragmatism, refers to the use of
individualism (La Roche et al., 2015; Poland, 2016). classifications as a means to help individuals with
As expressed in the DSM definition of mental disor- mental disorders. The DSM and ICD exist for a
der, psychopathology resides within the individual practical purpose: the desire to improve the condi-
and is not the manifestation of the interactions of tion of individuals who are suffering or impaired.
the individual with others or with the social forces This pragmatism creates a difference from scientific
around that individual (APA, 2013). The DSM and disciplines that are studied for their own sake, like

Classification in Traditional Nosologies 17

chemistry. The elements in the periodic table may and each group followed a three-​stage process. First,
change as new ones are discovered, but those addi- comprehensive literature reviews were conducted so
tions do not vary over time as a function of soci- that DSM-​IV reflected current knowledge. Second,
ety’s demands. Because psychiatric classifications existing data sets were reanalyzed to evaluate diag-
exist to serve a societal function, they can never be nostic concepts and provide information on the
objectively separated from that function, meaning performance of diagnostic criteria. Third, extensive
that societal values will always play a role in defin- field trials were conducted to address specific issues.
ing mental disorders. As the needs and priorities The DSM-​5 work group process appeared to be
of a society changes, so will the conditions that are fairly different from the work group process of its
included in these manuals. For example, both DSM predecessors. The work groups often had broader
and ICD considered including a disorder intended agenda, and their assignments were not just to one
to capture problematic (or addicted) Internet usage family of disorders. For example, the anxiety disor-
in their latest edition. der work group of DSM-​5 had responsibility for the
Finally, Sadler described the sixth implicit value categories of separation anxiety disorder, body dys-
of psychiatric classifications as traditionalism. The morphic disorder, social phobia, substance-​induced
diagnostic concepts in the DSMs and ICDs have a obsessive-​compulsive disorder, PTSD, and dissocia-
history. The modern classifications have been built tive amnesia. In addition, from the rationales pre-
on past classifications. Trying to maintain continu- sented for changes in categories, there appeared to
ity over time is important both for psychiatry and be obvious interaction across the work groups. For
for the other mental health professions. Sadler sug- example, substance-​induced obsessive-​compulsive
gested that the continuity of a classification system disorder, as mentioned earlier, involved interaction
results in this system becoming familiar, being with the work group for substance use disorders.
valued, and serving as the basis of a long-​standing Under the family of schizophrenic disorders, the
research and clinical infrastructure. psychotic disorders work group and the personality
disorders work group integrated their efforts.
Organization of Recent Classifications by The ICDs have followed a similar organiza-
Work Groups tional structure. However, being an international
The process used to formulate and revise the manual, the selection of individuals also included
DSMs and ICDs warrants comment. A lengthy international politics. The ICD-​10 was criticized
consultation process with panels of experts and the for largely being a European product develop by
profession at large was used to ensure the face or European experts. In response, the ICD-​11 explic-
content validity of diagnoses and widespread accep- itly made attempts to include on every work group
tance of the resulting system. The consultation individuals from low-​and middle-​income countries
process was partly a scientific exercise designed to (International Advisory Group, 2011).
produce a classification based on the best available There are many laudable features to the process
evidence and expertise and partly a social-​political used to revise and develop each edition. Each work
process designed to ensure the acceptability of the group faced a major undertaking that required care-
resulting product. Because scientific and political ful analysis of information as well as consultation
objectives often run counter to each other, compro- with other experts in the field. This division of labor
mises were necessary. into work groups probably contributed to the accep-
With DSM-​III, a task force handled the process tance of the resulting classifications. But there were
and established advisory committees. These com- also problems with the process. The initial structure
mittees were composed of experts whose task was for DSM-​III was established when the work groups
to identify and define diagnostic categories in their were identified. Each was given a defined area of
areas. Each committee also had a panel of consul- psychopathology. The separation into committees
tants to provide additional advice and information. along major topic areas led to both personal and
As the process continued, drafts of DSM-​III were conceptual conflicts. Psychopathology is not read-
circulated to the profession for review and com- ily divisible into discrete areas. Overlap occurred
ment. Finally, field trials were conducted to evaluate between various committees, leading to dispute.
the proposals and identify problems. Once a committee was established with a given
Although a similar process was used for DSM-​III-​ mandate, that committee was reluctant to relin-
R, DSM-​IV went a step further. Work groups were quish domains of psychopathology that might have
established to address specific diagnostic classes, been better classified elsewhere. The superordinate

18 Foundations and Perspectives

task force was responsible for resolving these dis- A variety of factors influence reliability esti-
putes and ensuring integration. Inevitably, political mates. For instance, variations in patient charac-
processes within and between work groups influ- teristics influence clinicians’ diagnostic decisions.
enced the solutions adopted. Additionally, who is Farmer and Chapman (2002) found that clinicians
selected to be a member of the work group is not were much more consistent in providing a diagnosis
without its own biases and limitations. Typically, of narcissistic personality disorder to men than to
those researchers with the most publications or women. Some studies have examined the influence
most notable reputations are selected. To date, it of variables such as race, age, and low socioeconomic
is rare for clinicians to be selected, and never has status on diagnosis (Abreu, 1999; James & Haley,
an individual with the diagnoses in question been 1995; Littlewood, 1992). Einfeld and Aman (1995)
included, despite these individuals’ perspectives suggest that reliability in DSM diagnoses appears to
potentially being useful regarding the usability and deteriorate markedly as patient IQ scores decrease.
acceptability of the resulting product (Kamens et Furthermore, it is important to note that reliability
al., 2019). The people selected to be on work groups estimates based on well-​controlled research studies
tend to publish together, receive grants together, are likely inflated relative to reliability in day-​to-​day
and otherwise have similar viewpoints, creating practice in clinical settings.
an ingroup that perpetuates a group-​think process
(Blashfield & Reynolds, 2012). Furthermore, the History
process of discussions among the work group is As noted earlier in this chapter, reliability
influenced by nonscientific processes. As noted by became a major focus of empirical criticisms of
Frances and Widiger (2012), two of the develop- psychiatric diagnosis during the 1950s and 1960s.
ers of DSM-​IV, experts tend to be very opinionated Generally, the impression from these studies was
and assertive in their beliefs, leading to the person that psychiatrists and clinical psychologists, when
with the loudest voice being the most influential. independently diagnosing the same cases, did
not agree on the diagnoses that they were assign-
Measurement and Methodological Issues ing to cases. Interestingly, as the methodology of
The final section of this chapter addresses more these studies improved, the estimates of reliabil-
practical concerns about the classification of mental ity generally appeared more positive than in the
disorders. While it is good to debate the ontologi- early, rather hastily designed studies. One study in
cal status of the term “mental disorder” and con- this series (Ward et al., 1962) made the additional
sider the political forces that impact classification conclusion that the reason for this relative lack of
schemes, at some point, practical decisions must diagnostic agreement among clinicians (i.e., poor
be made regarding actual patients. Many of these reliability) was that the definitions of the diagnos-
practical concerns embody decisions about mea- tic categories in DSM-​I were too vague. Although
surement, or how one assesses the nature of the the methodology of the Ward et al. study had seri-
condition. We adopt some of the standard terms of ous limitations (Blashfield, 1984), this conclusion
psychological measurement theory, including con- appealed to the field, and the Ward et al. (1962)
cepts like reliability and validity, to elucidate issues paper was often cited prior to the publication
surrounding psychiatric diagnosis. of DSM-​III, when diagnostic criteria were used
to improve the precision of defining diagnostic
Reliability categories.
The reliability of a classification of mental dis- Another source of variability in early research on
orders is the degree of diagnostic agreement among reliability was the statistical procedure used to pro-
users. Reliability is clearly important; diagnoses vide reliability estimates. In earlier years, this was a
have little value for communication or prediction serious problem (Zubin, 1967). By the mid-​1970s,
if there are high levels of disagreement among cli- a statistic named kappa became the standard tech-
nicians. As Kendell (1975) pointed out, the accu- nique for estimating diagnostic reliability. Kappa
racy of clinical and prognostic decisions based on a corrects for chance levels of agreement between rat-
diagnosis cannot be greater than the reliability with ers and thus is an improvement on a simple per-
which the diagnosis is made, and most writers allege centage of agreement. However, a limitation of this
that reliability places an upper limit on the validity statistic is its instability when the base rate of a diag-
of a given diagnosis (Spitzer & Fleiss, 1975; Spitzer nosis within a sample is less than 5% (Spitznagel &
& Williams, 1980). Helzer, 1985).

Classification in Traditional Nosologies 19

Assessing Reliability equally predicted clients’ functioning at a 5-​year
It is instructive to compare reliability as applied follow-​up, suggesting that the difference in reli-
to psychiatric classification with reliability as ability may not have much practical importance.
applied to psychological tests. In test theory, “reli- Diagnostic disagreement can occur when clinicians
ability” refers to the consistency of scores obtained have different kinds and amounts of information
with the same test on different occasions or with on which to base diagnosis. This problem may arise
different sets of equivalent items (Anastasi, 1982). from differences in clinicians’ ability to elicit infor-
If a test is reliable, parallel scales constructed from mation, the way patients respond to questions, and
an equivalent pool of items will yield the same mea- the availability of information from other sources.
surement values. The extent to which this does not Thus, there are important sources of variance that
occur indicates the extent to which measurement is can contribute to unreliability, including differ-
influenced by error. Traditionally, the reliability of ences in clinical skill, patient responsiveness, and
psychological tests is assessed in three ways: (1) test-​ diagnostic setting.
retest reliability, (2) alternative forms, and (3) inter- Internal Consistency. Internal consistency mea-
nal consistency. A fourth method directly relevant sures (split-​half techniques and coefficient alpha)
to the clinical enterprise is interrater reliability, or assume each item on a scale is like a miniature scale.
the consistency of different diagnosticians regarding Thus, internal consistency estimates the extent to
the same patient. which the items in a scale are homogeneous. In psy-
Test-​Retest Reliability. The test-​ retest method chological testing, this estimate of reliability is the
assumes that the administration of the same scale most common. Morey (1988) examined the inter-
at different points in time represents parallel tests. nal consistency of diagnostic criteria for personality
Memory for items is the most common confound disorders and found low correlations among criteria
with this approach. High test-​retest reliability is to used to diagnose the same disorder. Other studies
be expected only when measuring a variable assumed have found higher estimates of internal consistency,
to be stable; some mental disorders are assumed to but using logistic regression and calculations of sen-
follow a relatively stable course (e.g., autism spec- sitivity and specificity have concluded that some
trum disorders), but many disorders (e.g., mood criteria for certain personality disorders could be
disorders) are assumed to fluctuate across time. In a dropped because they do not form a cohesive diag-
multisite collaborative study of DSM-​IV disorders, nosis (Farmer & Chapman, 2002). These criticisms
Zanarini et al. (2000) found that test-​retest kappa (among others) have led to some of the changes pro-
coefficients ranged from 0.35 to 0.78 for a variety of posed in DSM-​5’s Section III regarding personality
clinical disorders and from 0.39 to 1.00 for person- disorder diagnosis. However, care should be taken
ality disorders. However, more recent research has with such conclusions. It is reasonable to posit het-
questioned just how consistent personality disorder erogeneous symptom groupings for which internal
diagnoses are across time, finding substantial fluc- consistency estimates are therefore inappropriate
tuation across categorical personality disorder types means of measurement, just as test-​retest estimates
(Hopwood et al., 2013). are inappropriate for diagnoses expected to change
Alternative Forms. The alternative-​form method over time.
uses equivalent or parallel measures of the same Interrater Reliability. The three forms of reliabil-
construct. Ideally, different sources of informa- ity just discussed focus on the construct underlying
tion should converge on the same conclusions. the diagnosis. However, discrepancies can also occur
Hilsenroth, Baity, Mooney, and Meyer (2004) in the application of the diagnosis. Two clinicians,
examined three sources of information regarding for example, may disagree about what diagnosis
depressive symptoms: in vivo interviews, video- is best for the same case. In studies of interrater
taped interviews, and chart reviews. Clinicians reliability, two or more clinicians interview each
made reliable ratings of depressive symptoms across patient either conjointly in a single interview or in
in vivo interviews and videotaped interviews, but separate interviews close together in time. In DSM-​I
chart reviews were not consistent with either. and DSM-​II, consistency among clinicians was low,
Similarly, Samuel and colleagues (2013) examined and the advent of diagnostic criteria in DSM-​III was
the convergence of clinician-​assigned personality supposed to increase reliability. However, claims
disorder diagnoses, self-​report questionnaires, and that reliability has increased seem to be overstated;
semi-​structured interviews. They found that the diagnostic reliability does not seem to be substan-
convergence of these methods was low, but they tially different over time (Vanheule et al., 2014).

20 Foundations and Perspectives

Other documents randomly have
different content
also verhalten sich die Lichtstärken von A und B wie die Quadrate
ihrer Entfernungen vom Schirm.
Die gebräuchlichste Lichteinheit ist die N o r m a l k e r z e oder
d e u t s c h e V e r e i n s k e r z e, das Licht einer Paraffinkerze von 22
mm Durchmesser und 30 mm Flammenhöhe. Es liefert z. B. ein
Petroleumrundbrenner von 25 mm Durchmesser bei 54 g
Ölverbrauch pro Stunde 16 Kerzen Lichtstärke.
Unter 1 Meterkerze versteht man die Beleuchtungsstärke,
welche eine kleine Fläche von 1 Normalkerze in 1 m Entfernung bei
senkrechter Beleuchtung empfängt. Eine Flamme von N
Normalkerzen Lichtstärke liefert demnach in a m Entfernung bei
N
senkrechtem Einfallen eine Beleuchtung von 2 Meterkerzen, bei
a
N
schiefem: 2 cos α Meterkerzen.
a
Aufgaben:
109. Bei einem Photometer von Rumford ist eine deutsche
Vereinskerze 64 cm, eine Petroleumlampe 1,53 m vom Schirm
entfernt, so daß die Schatten gleich dunkel erscheinen. Wie viele
Normalkerzen beträgt die Leuchtkraft dieser Lampe?
110. Wie viele Meterkerzen beträgt im vorigen Beispiel die
Beleuchtung des Schirmes durch die Lampe allein?
111. In welcher Entfernung beleuchten 3 Argandbrenner à 22
N.K. eine Wand ebenso stark als eine Vereinskerze in 1⁄2 m
Entfernung? Wie viele Meterkerzen hat die Beleuchtung?

190. Reflexion des Lichtes.

Trifft das Licht auf die Grenzfläche zweier Stoffe (Medien), so
teilt es sich in zwei Teile; der eine Teil dringt in das zweite Medium
ein (und wird entweder durchgelassen oder verschluckt, wovon
später), der andere Teil kehrt in das erste Medium zurück, wird
z u r ü c k g e w o r f e n o d e r r e f l e k t i e r t.
 Ist diese Grenzfläche rauh und uneben wie bei Holz, Stein, Erde,
Papier, so wird das auffallende Licht nach allen Seiten hin
zurückgeworfen, gleichgültig, wie es einfällt: z e r s t r e u t e
Z u r ü c k w e r f u n g o d e r d i f f u s e R e f l e x i o n. Sie bewirkt,
daß wir solche Gegenstände überhaupt sehen, da die reflektierten
Lichtstrahlen in unser Auge fallen, wo es sich auch befinden mag.
Wir nennen einen Gegenstand h e l l, wenn er verhältnismäßig viele
Lichtstrahlen zurückwirft (weißes Papier), dagegen dunkel, wenn er
sehr wenig Licht zurückwirft (braune Stoffe, Erde u. s. w.) und
s c h w a r z, wenn er fast gar kein Licht zurückwirft. Einen a b s o l u t
s c h w a r z e n Körper, der gar kein Licht zurückwirft, gibt es nicht;
ein solcher müßte auch bei der stärksten Beleuchtung ganz
unsichtbar sein; sehr schwarz ist Tusch und Lampenruß.

191. Definition des optischen Bildes.

Das Auge sieht einen Punkt, wenn von den Lichtstrahlen, die
von dem Punkte ausgehen, ein (kegelförmiges) Bündel ins Auge
fällt.

Fig. 241.
 Werden alle Strahlen eines solchen Bündels durch irgend welche
Ursachen von ihrer Bahn abgelenkt, so daß sie nachher wieder in
einem Punkte A′ oder A′′′ (Fig. 241) zusammentreffen, so nennt
man diesen Punkt A′ oder A′′′ ein optisches Bild des Punktes A.
Denn die Lichtstrahlen setzen dann ihren geradlinigen Weg fort und
bilden wieder ein kegelförmiges Strahlenbündel. Trifft dieses Bündel
in das Auge, so hat es denselben Eindruck, wie wenn es vom
Strahlenbündel des leuchtenden Punktes getroffen würde; das Auge
glaubt in A′ den leuchtenden Punkt zu sehen. Deshalb nennt man A′
das Bild von A, und zwar ein reelles Bild; ebenso A′′′.
Werden jedoch die Strahlen eines solchen Bündels so abgelenkt,
daß sie sich nicht wirklich in einem Punkte schneiden, aber doch so
laufen, als wenn sie alle von einem Punkte A′′ herkämen, so nennt
man diesen Punkt A′′ ein virtuelles Bild. Wird ein Auge in den
Gang dieser Lichtstrahlen gebracht, so hat es den Eindruck, wie
wenn die Strahlen wirklich von A′′ herkämen, es glaubt, in A′′ den
leuchtenden Punkt A zu sehen.
Werden aber die Strahlen so abgelenkt, daß sie nach der
Ablenkung keinen Vereinigungsort (weder einen reellen, noch
virtuellen) haben, so hat das Auge, das man in den Gang solcher
Lichtstrahlen bringt, wohl noch den Eindruck von Licht, Helligkeit,
Farbe, aber nicht mehr den Eindruck, als sehe es den Punkt A. Es
entsteht kein optisches Bild.

192. Reflexionsgesetze.
Ist die Grenzfläche zweier Medien glatt, so erfolgt die Reflexion
nach den Reflexionsgesetzen (regelmäßige Reflexion):
1) Jeder Lichtstrahl wird nur nach einer Richtung
reflektiert.
2) Der einfallende Strahl, der reflektierte und das
Einfallslot liegen in einer Ebene, Reflexionsebene. D i e
Reflexionsebene steht senkrecht auf der
r e f l e k t i e r e n d e n E b e n e.
 3) Der
Einfallswinkel ist
gleich dem
Reflexionswinkel, d. h.
der Winkel, welchen der
einfallende Strahl mit Fig. 243.
dem Einfallslot bildet, ist
gleich dem Winkel, welchen der reflektierte
Fig. 242. Strahl mit dem Einfallslot bildet.
Der R e f l e x i o n s a p p a r a t: Auf
einem Brettchen ist ein im Halbkreise gebogenes Blech befestigt, in
Grade geteilt und in der Mitte mit einem Spalte versehen. Im
Mittelpunkte des Kreises (Fig. 243) ist ein kleiner Spiegel drehbar
aufgestellt und mit einem Zeiger verbunden, welcher auf ihm
senkrecht steht, also die S p i e g e l n o r m a l e oder das
E i n f a l l s l o t darstellt, und mit seinem Ende längs des Halbkreises
sich bewegt. Läßt man durch den Spalt einen Lichtstrahl auf den
Spiegel fallen, dreht diesen, so daß der Zeiger etwa auf 32° zeigt,
also der Einfallswinkel 32° beträgt, so wird das Licht reflektiert, und
trifft den Halbkreis bei 64°; demnach ist auch der Reflexionswinkel
32°. Durch Versuche mit verschiedenen Einfallswinkeln findet man
das Gesetz bestätigt.

193. Planspiegel.
Eine glatte Grenzfläche zweier Medien nennt
man Spiegel, und zwar Planspiegel, wenn die
F l ä c h e e b e n i s t.
Wenn ein Bündel paralleler Lichtstrahlen auf einen Planspiegel
fällt, so sind auch die reflektierten Strahlen unter sich parallel.
Tr e f f e n L i c h t s t r a h l e n v o n e i n e m l e u c h t e n d e n
Punkte aus divergent den Spiegel, so
divergieren auch die reflektierten Strahlen und
zwar so, als ob sie von einem Punkte herkämen,
der hinter dem Spiegel liegt eben so weit wie
der leuchtende Punkt vor demselben und zwar
in der Verlängerung der vom leuchtenden
Punkte auf den Spiegel gezogenen Senkrechten
( S p i e g e l n o r m a l e ).

Fig. 244.

Ableitung: Es sei (Fig. 244) SS′ der ebene Schnitt des Spiegels
und L der leuchtende Punkt; ich mache LS ⊥ SS′, verlängere LS, so
daß L′S = LS, und beweise, daß jeder reflektierte Strahl durch L′
geht. Sei LA ein beliebiger Strahl, so ziehe ich L′A und verlängere ihn
nach AA′, so ist △ LAS ≅ △ L′AS; [denn SL = SL′, SA = SA, ∢ LSA =
∢ L′SA = R]; also ∢ LAS = ∢ L′AS; aber ∢ L′AS = S′AA′, demnach ∢
LAS = ∢ S′AA′ also auch, wenn MA ⊥ SS′ (Einfallslot), ∢ LAM = ∢ A′
AM; AA′ ist also, da Einfallsw. = Reflexionsw., der reflektierte Strahl
von LA. Was von LA bewiesen wurde, kann ebenso von jedem
beliebigen anderen Strahle LB, LC etc. bewiesen werden; also gehen
die reflektierten Strahlen wirklich so, als wenn sie von L′ herkämen.
Man sagt: Der Planspiegel entwirft von dem leuchtenden
Punkte L ein virtuelles Bild in L′, das in der Verlängerung der
Spiegelnormale eben so weit hinter dem Spiegel liegt als der
leuchtende Punkt vor dem Spiegel. Das angegebene Gesetz gilt
nicht bloß von Strahlen, welche in der Ebene LSS′ liegen. Läßt man,
wie in Figur 245 angedeutet, von L Strahlen ausgehen, die nicht in
einer Ebene liegen, so werden sie auch so reflektiert, als wenn sie
vom Punkte L′ herkämen, dessen Lage dem angegebenen Gesetze
entspricht. Beweis ebenso.

Fig. 245.

Aufgaben:
112. Unter welchem Gesichtswinkel sieht man einen 1,2 m
hohen Gegenstand in 15 m Entfernung?
113. Unter welchem Gesichtswinkel sieht man sich selbst, wenn
man 4 m vor einem Spiegel steht, bei 1,7 m Größe? Wie groß muß
der Spiegel sein, um die ganze Figur zu zeigen?
114. Dreht man einen Spiegel um den Winkel α, so dreht sich
jeder von ihm reflektierte Strahl um den Winkel 2α. Beweis?
115. Wenn man 3,6 m vor einem Spiegel steht, unter welchem
Gesichtswinkel sieht man dann das Spiegelbild eines 60 cm großen
Gegenstandes, der 2 m (10 m) vor dem Spiegel steht?
 115 a. Welche Bewegung macht das Bild eines Punktes, der
sich einem Spiegel nähert?
115 b. Wenn bei einem Glasspiegel nicht nur die hintere mit
Metall belegte Fläche, sondern auch die vordere Glasfläche spiegelt,
um wie viel scheinen die zwei Bilder eines Punktes voneinander
entfernt zu sein?

194. Winkelspiegel.
Zwei unter einem Winkel
gegeneinander geneigte
Planspiegel bilden einen
W i n k e l s p i e g e l. Befindet sich
ein leuchtender Punkt zwischen
beiden, so entstehen von ihm
mehrere Bilder. Es sei A der
leuchtende Punkt (Fig. 246), so
entwirft Spiegel I das Bild A′; da
dies Bild vor Spiegel II liegt, so
entwirft dieser das Bild A′′; dies
Bild liegt vor I, also entwirft I das
Bild A′′′; dies liegt vor II, also
entwirft II das Bild A′′′′; A′′′′
Fig. 246. liegt hinter I, also spiegelt es
sich nicht mehr. Nun spiegelt sich
A auch in II; II entwirft also das Bild B; von ihm entwirft I das Bild
B′; von ihm entwirft II das Bild B′′; von ihm I das Bild B′′′, das bei
der in der Figur angenommenen Anordnung (∢ v. 45°) mit A′′′′
zusammenfällt.
Die Bilder liegen in einem K r e i s e, dessen Ebene senkrecht zur
Schnittlinie der Spiegel ist; ihre Anzahl, den Gegenstand
mitgerechnet, ist 8, allgemein = 360 , wenn die Neigung der beiden
a
Spiegel a° ist. Die Anzahl der Bilder wächst, wenn der Winkel kleiner
wird. Das K a l e i d o s k o p besteht aus drei unter je 60° gegen
einander geneigten spiegelnden Glasstreifen, die in eine Röhre
gefaßt sind; vor derselben zwischen zwei Deckgläsern liegen kleine
Stückchen farbigen Glases, welche durch Drehen und Schütteln
immer in andere Lage gebracht werden können. Durch die
Spiegelung setzen sich aus den Glasstückchen und deren
Spiegelbildern sechsseitige Sternfiguren zusammen, die durch ihre
Regelmäßigkeit gefallen und durch ihre Wandelbarkeit ergötzen.
Das D e b u s k o p ist ein Winkelspiegel aus zwei Silberspiegeln
zusammengestellt; sein Winkel kann beliebig verändert werden;
stellt man es auf eine Zeichnung, so sieht man sie zu einem
regelmäßigen Stern vervielfältigt, und kann sich so aus
unregelmäßigen Strichen Motive zu gefälligen Sternmustern suchen.
Aufgaben:
116. Bei einem Winkelspiegel von 45° ist ein Strahl nach
zweimaliger Brechung senkrecht zu seiner ursprünglichen Richtung.
116 a. Bei einem Winkelspiegel von 90° ist ein Strahl nach
zweimaliger Brechung seiner ursprünglichen Richtung parallel.

195. Sphärische Spiegel.

Ein s p h ä r i s c h e r S p i e g e l ist gekrümmt wie die
O b e r f l ä c h e e i n e r K u g e l; ist dabei die i n n e r e , h o h l e
Seite spiegelnd, so heißt er ein H o h l s p i e g e l oder
k o n k a v e r s p h ä r i s c h e r S p i e g e l; ist die ä u ß e r e Seite
spiegelnd, so heißt er ein k o n v e x e r S p i e g e l.
Brennpunkt des Hohlspiegels.
Die H o h l s p i e g e l sind gewöhnlich rund, und die
Verbindungslinie des Krümmungsmittelpunktes mit der Mitte des
Spiegels, also OM, ist die H a u p t a c h s e; jede andere durch O
gehende Linie heißt eine Nebenachse des Spiegels.
 Fig. 247.

Wir lassen ein Bündel paralleler Lichtstrahlen der Hauptachse

MO parallel auf den Spiegel fallen (Fig. 247) und untersuchen den
G a n g d e r r e f l e k t i e r t e n S t r a h l e n. Es sei LJ ein solcher
Strahl, so kann man das in J liegende Flächenstückchen des Spiegels
als eben betrachten; das Einfallslot ist dann der Krümmungsradius
JO, da er senkrecht auf der Fläche steht. Macht man den
Reflexionswinkel gleich dem Einfallswinkel, und nennt den
Schnittpunkt des reflektierten Strahles mit der Achse F, so ist LJO =
OJF (Reflexionsges.), LJO = JOF (Wechselwinkel), also OJF = JOF,
somit △ FJO gleichschenklig, oder JF = FO. Wir nehmen nun an, J
liege so nahe an M, daß man ohne nennenswerten Fehler JF = FM
setzen kann, so ist auch FM = FO, d. h. der reflektierte Strahl
schneidet die Achse in der Mitte des Radius. Für jeden anderen
parallelen Strahl L′J′ gilt dieselbe Ableitung und das gleiche Resultat,
ebenso auch für jeden Strahl, der in einem andern Achsenschnitte
des Spiegels liegt.
Folglich: Alle parallel der Hauptachse auffallenden
Strahlen gehen nach der Reflexion durch denselben Punkt F
um so genauer, je näher sie an der Mitte M auffallen,
Z e n t r a l s t r a h l e n.
Läßt man Sonnenlicht auf den Hohlspiegel fallen, so wird es in
einen kleinen Fleck vereinigt, ebenso aber auch alle
W ä r m e s t r a h l e n; es ist deshalb in diesem Punkte (Flecke) sehr
viel Wärme vereinigt, so daß ein leicht entzündlicher Körper dort
entzündet wird. Man nennt deshalb diesen Punkt F den
B r e n n p u n k t oder F o k u s, seinen Abstand vom Spiegel, also FM,
die B r e n n w e i t e oder F o k a l d i s t a n z, f, und den Hohlspiegel
auch B r e n n s p i e g e l.

Fig. 248.

Ist die Öffnung eines Hohlspiegels einigermaßen groß im

Verhältnis zum Radius, so weichen die reflektierten Strahlen
beträchtlich von dem eben beschriebenen Gange ab, gehen also
nicht mehr alle durch den Brennpunkt, sondern berühren eine
krumme Linie, welche im Brennpunkte eine Spitze hat, Brennlinie
oder katakaustische Linie.
Betrachtet man nicht nur den in der Figur gezeichneten
Achsenschnitt, sondern alle Achsenschnitte, so liefert jeder eine
Brennlinie; sie erfüllen eine Brennfläche, die katakaustische Fläche.

196. Bildgleichung des Hohlspiegels.

Wir lassen das Licht ausgehen von einem auf der Hauptachse
im Endlichen liegenden Punkte L und untersuchen den Gang der
reflektierten Strahlen (Fig. 249). Ist LJ der einfallende Strahl, OJ das
Einfallslot, JB der reflektierte Strahl, so daß LJO = OJB, und B
dessen Schnittpunkt mit der Achse, so ist in △ BJL der Winkel an der
Spitze halbiert, daher
LJ : JB = LO : OB.

Fig. 249.

Betrachten wir nur Z e n t r a l s t r a h l e n, so daß ohne

nennenswerten Fehler LJ = LM und BJ = BM, so ist
LM : BM = LO : OB.
Bezeichnet man den Abstand des leuchtenden Punktes vom
Spiegel, also LM, mit a, den Abstand des Punktes B vom Spiegel mit
b und setzt r = 2 f, so wird aus obiger Proportion:
a : b = (a - 2 f) : (2 f - b); hieraus
2 a f - a b = a b - 2 b f,
2 a f + 2 b f = 2 a b, und durch Division mit 2 a b f
1 + 1 = 1 . Aus dieser Gleichung kann b berechnet werden.
a b f
Für jeden anderen Zentralstrahl LJ gilt dieselbe Ableitung, folglich
gehen alle reflektierten Strahlen durch denselben Punkt B. Man hat
also den Satz: Liegt der leuchtende Punkt auf der Hauptachse,
so gehen die reflektierten Strahlen alle durch einen Punkt B
der Hauptachse. Dieser Punkt B ist deshalb ein reelles Bild des
leuchtenden Punktes L, und sein Abstand b vom Spiegel berechnet
sich aus der Gleichung 1 + 1 = 1 (B i l d g l e i c h u n g).
a b f
 Lichtpunkt L und Bildpunkt B liegen harmonisch zu O und M, oder Lichtpunkt
und Bildpunkt teilen den Radius äußerlich und innerlich in demselben Verhältnisse.

197. Größe, Art und Lage der Bilder beim

Hohlspiegel.
Hält man in B einen kleinen Schirm, so wird ein Punkt desselben
von allen reflektierten Strahlen getroffen, also beleuchtet: das Bild
ist auf einem Schirm a u f f a n g b a r.

Fig. 250.

Liegt der leuchtende Punkt nicht in L (Fig. 250), sondern

senkrecht zur Achse etwas entfernt in L′, so kann man L′O als
dessen Achse ansehen und findet sein Bild in B′, wobei auch B′B
senkrecht zur Achse. Besteht der leuchtende Körper aus der Linie LL′
, so ist das Bild BB′.
Vergleicht man die Größe des Bildes BB′ mit der Größe des
Gegenstandes LL′, so hat man LL′ : BB′ = LO : BO; aber LO : BO =
LM : BM = a : b (siehe Ableitung), also LL′ : BB′ = a : b; d. h. die
Größen von Gegenstand und Bild verhalten sich wie ihre
Abstände vom Spiegel.
 Fig. 251.

Wir betrachten an der Hand der Bildgleichung 1 = 1 - 1 die

b f a
Bilder, welche entstehen, wenn der leuchtende Punkt vom
Unendlichen immer näher an den Spiegel rückt, und kontrollieren die
Richtigkeit durch einfache Versuche mittels eines Hohlspiegels, einer
Flamme und eines beweglichen Papierschirmes.
Liegt der Punkt im Unendlichen, so ist a = ∞, 1 = 0, also 1 =
a b
1 , also b = f; das Bild liegt im Brennpunkte. Rückt L vom
f
Unendlichen gegen den Spiegel (Fig. 251), so wird a kleiner, 1
a
größer, demnach 1 kleiner, also b größer; das Bild rückt vom
b
Brennpunkte aus vom Spiegel weg, anfangs sehr langsam, später
rascher. Rückt L bis in den Mittelpunkt O, so ist a = 2 f, also b = 2 f,
d. h. auch das Bild ist im Mittelpunkt angekommen und ist so groß
wie der Gegenstand. Während der leuchtende Punkt vom
Unendlichen bis zum Mittelpunkt rückt, rückt das Bild vom
Brennpunkte bis zum Mittelpunkte; die Bilder sind dabei
verkehrt, reell, verkleinert, aber wachsend.
 Fig. 252.

Rückt L noch näher an den Spiegel (Fig. 252), so wird a noch

kleiner, 1 größer, somit 1 kleiner, also b größer, d. h. das Bild rückt
a b
noch weiter vom Spiegel. Kommt der leuchtende Punkt in den
Brennpunkt, so ist a = f, also 1 = 0 und b = ∞, d. h. das Bild liegt
b
im Unendlichen; die reflektierten Strahlen laufen parallel. Während
der leuchtende Punkt vom Mittelpunkte bis zum
Brennpunkte rückt, rückt das Bild vom Mittelpunkte ins
Unendliche; die Bilder sind verkehrt, reell, vergrößert und
wachsend. Der Brennpunkt selbst bekommt dadurch noch eine
weitere Bedeutung: die vom Brennpunkt ausgehenden
Strahlen sind nach der Reflexion parallel der Achse.

Fig. 253.

Rückt L noch näher an den Spiegel (Fig. 253), so wird a < f,

also 1 > 1 , somit b negativ; das bedeutet, das Bild liegt h i n t e r
a f
d e m S p i e g e l (wie beim Planspiegel), ist demnach v i r t u e l l ,
d. h. die Lichtstrahlen laufen nach der
Reflexion so, als wenn sie von einem hinter
d e m S p i e g e l l i e g e n d e n P u n k t e h e r k ä m e n. Die Bilder
können nicht auf dem Schirme aufgefangen werden. So lange a
noch nahezu = f ist, ist b sehr groß, die Bilder liegen sehr weit hinter
dem Spiegel und sind deshalb stark vergrößert. Rückt der
leuchtende Punkt ganz an den Spiegel, ist also a = 0, also 1 = ∞,
a
so ist 1 = - ∞, also b = 0, d. h. auch das Bild liegt am Spiegel.
b
Während der leuchtende Punkt vom Brennpunkte an den
Spiegel rückt, liegt das Bild hinter dem Spiegel und rückt
vom Unendlichen auch bis zum Spiegel: die Bilder sind dabei
virtuell, aufrecht und vergrößert, aber abnehmend.

198. Konstruktion der Bilder beim Hohlspiegel.

 Fig. 254.

Man kann Ort, Art und Größe dieser Bilder auch durch eine
g e o m e t r i s c h e K o n s t r u k t i o n finden durch Benützung der
beiden Sätze: I. Ein parallel der Achse ausfallender Strahl
geht nach der Reflexion durch den Brennpunkt, II. ein durch
den Krümmungsmittelpunkt gehender Strahl geht auf
demselben Wege zurück, da er den Spiegel senkrecht trifft. Man
kann noch den dritten dazu nehmen: ein durch den Brennpunkt
gehender Strahl wird nach der Reflexion parallel der Achse.
Man wählt zu dem gegebenen leuchtenden Punkte L einen senkrecht
zur Achse etwas seitwärts gelegenen Punkt L′, zieht die zwei eben
angegebenen Strahlen und ihre reflektierten, so ist der Schnittpunkt
B′ dieser reflektierten Strahlen das Bild von L′; zieht man noch B′B
senkrecht zur Achse, so ist BB′ das Bild von LL′. Auf solche Weise
sind die Konstruktionen in Fig. 254 ausgeführt unter Benützung aller
drei Sätze. Jedoch ist zu beachten, daß man nur Zentralstrahlen
benützen darf, wenn man eine einigermaßen brauchbare
Konstruktion bekommen will, daß aber gerade bei Benützung von
Zentralstrahlen der Schnittpunkt der reflektierten Strahlen sehr
unsicher wird. Die Ausführung solcher Konstruktionen ist deshalb
zwar gut, wenn man sich den Gang der Lichtstrahlen klar machen
will; aber für praktische Zwecke zieht man die leichte Berechnung
mittels der Bildgleichung vor.
Man kann auch leicht eine geometrische Konstruktion angeben, so daß b dem
aus der Bildgleichung entspringenden Wert a f entspricht. Z. B. Auf den
a-f
Schenkeln eines beliebigen Winkels XOY trage man von O aus OF = OF′ = f,
vervollständige damit den Rhombus OFMF′ und zieht durch M eine beliebige
Gerade, welche OX in A, OY in B schneidet, so ist, wenn OA = a, OB = b. Beweis?
Aufgaben:
117. Vor einem Hohlspiegel von 80 cm Brennweite befindet sich
in 12 m Entfernung ein Gegenstand von 1,4 m Höhe. Wo liegt das
Bild und wie groß ist es?
118. Vor einem Hohlspiegel von 2 m Krümmungsradius befindet
sich in 40 cm Abstand ein Gegenstand. Wo liegt das Bild?
 118a. Wie groß ist der Krümmungsradius eines Hohlspiegels,
welcher von einem 160 cm entfernten Punkt ein Bild in 40 cm
Entfernung entwirft?

199. Anwendung des Hohlspiegels;

Brennspiegel.
Der Hohlspiegel wird als B r e n n s p i e g e l verwendet. Die
Sonne hat einen Durchmesser von 185 640 geogr. M. und eine
Entfernung von 19 936 000 geogr. M.; das Bild der Sonne, das der
Hohlspiegel erzeugt, liegt im Brennpunkte; ist die Brennweite etwa
100 cm, so ist der Durchmesser des Sonnenbildes = x zu berechnen
aus 19 936 000 : 185 640 = 100 : x; x = 0,93 cm. Alle auf den
Spiegel fallenden Sonnenstrahlen werden demnach auf eine
Kreisfläche von 0,93 cm Durchmesser vereinigt. Hat der runde
Hohlspiegel etwa einen Durchmesser von 50 cm, so ist seine Fläche
502 · 3,14 qcm, die Fläche des Bildes ist 0,932 · 3,14 qcm, also
4 4
502 mal kleiner; die Brennfläche erhält also ca. 2900 mal so viel
0,932
Licht und Wärme wie eine direkt von der Sonne beschienene
gleichgroße Fläche. Davon geht etwa die Hälfte bei der Reflexion
verloren; doch bleibt genug übrig, um eine intensive Erhitzung zu
erzielen. Mit solchen Hohlspiegeln kann man Platin schmelzen, sogar
verdampfen.
Man verwendet die durch große Brennspiegel gesammelte Sonnenwärme
auch zum Heizen eines kleinen Dampfkessels. Dabei ist der Hohlspiegel drehbar
aufgestellt, um dem Gang der Sonne folgen zu können. Tschirnhaus machte 1687
zuerst einen großen Brennspiegel aus Kupfer mit drei Leipziger Ellen Durchmesser,
zwei Ellen Brennweite und erzielte mächtige Wirkung. Als die Akademie von
Florenz vor dem Brennspiegel große Eismassen aufstellte und in den Brennpunkt
ein Thermometer brachte, sank dieses; warum?
 200. Beleuchtungsspiegel.
Der Arzt verwendet den Hohlspiegel, um das Innere des Auges
oder des Ohres oder den hintern Teil der Rachenhöhle oder den
Kehlkopf stark zu beleuchten und so auf Krankheit untersuchen zu
können, indem er durch ein kleines in der Mitte des Spiegels
angebrachtes Loch blickt; ein solcher Spiegel heißt dann je nach
seinem Zwecke Augenspiegel u. s. w. (Helmholtz, 1851.)
B e l e u c h t u n g f e r n l i e g e n d e r G e g e n s t ä n d e. Stellt
man eine stark leuchtende Lampe in den Brennpunkt des
Hohlspiegels, so wird alles auf den Hohlspiegel fallende Licht (das
nicht absorbiert wird) in einer zur Achse parallelen Richtung
reflektiert, kann demnach einen fern liegenden Gegenstand gut
beleuchten. Das vom Hohlspiegel reflektierte Licht ist jedoch nicht
vollkommen parallel, sondern divergiert etwas; denn 1) ist es nicht
möglich, die Lampe genau in den Brennpunkt zu stellen; 2) die
Flamme ist nicht nur ein leuchtender Punkt, sondern ein leuchtender
Fleck; die von den verschiedenen Punkten derselben ausgehenden
Lichtstrahlen werden demnach auch nach verschiedenen Richtungen
reflektiert; 3) um möglichst viel Licht mit einem solchen
R e f l e k t o r aufzufangen und fortzuschicken, macht man den
Hohlspiegel möglichst groß; aber die nahe am Rande ausfallenden
Strahlen werden dann nicht mehr in derselben (zur Achse parallelen)
Richtung reflektiert wie die Zentralstrahlen. Das vom Hohlspiegel
reflektierte Licht beleuchtet demnach nicht bloß eine dem
Hohlspiegel gleich große, sondern eine verhältnismäßig viel größere
Fläche, etwa ein ganzes Haus.
Man wendet deshalb sphärische
Hohlspiegel von mehr als etwa 60° Weite
nicht an; will man noch mehr Licht
auffangen, so benützt man parabolische
Hohlspiegel (Fig. 255). Solche sind
gekrümmt wie das
R o t a t i o n s p a r a b o l o i d; das ist die
Fläche, welche entsteht, wenn man eine Fig. 255.
Parabel um ihre Achse dreht. D i e P a r a b e l h a t d i e
Eigenschaft, daß alle vom Brennpunkte
ausgehenden Lichtstrahlen parallel der Achse
r e f l e k t i e r t w e r d e n. Ist das Licht eine Flamme, deren Punkte
nicht alle im Brennpunkte stehen können, so divergiert das
reflektierte Licht auch beträchtlich. Benützt man aber elektrisches
Licht, indem man die positive Kohle mit ihrem „Krater“ dem Spiegel
zukehrt, so hat ja das elektrische Licht nur geringe Ausdehnung
(einige mm), deshalb divergiert das reflektierte Licht nur wenig, und
sehr weit entfernte Gegenstände können noch sehr gut beleuchtet
werden. So wendet man das elektrische Licht auf Leuchttürmen, im
Kriege u. s. w. an.
Die S t i r n l a m p e n der Lokomotiven sind meist aus sehr vielen
kleinen Planspiegeln zusammengesetzt, die so auf einer gekrümmten
Fläche festgekittet sind, daß sie möglichst gut mit einer
Parabelfläche übereinstimmen. Der Beleuchtungszweck wird dadurch
recht gut erreicht.
Hohlspiegel von geringer Krümmung benützt man als
To i l e t t e -, R a s i e r s p i e g e l u. s. w., indem man sich so nahe vor
den Spiegel stellt, daß man sich zwischen Brennpunkt und Spiegel
befindet und nun, ähnlich wie beim Planspiegel sein eigenes,
virtuelles, aufrechtes, aber nun v e r g r ö ß e r t e s Bild betrachtet.
 201. Konvexe Spiegel.

Fig. 256.

Beim konvexen Spiegel spiegelt die ä u ß e r e Fläche einer

sphärischen Fläche. Da die Anwendung sehr unbedeutend ist, so
genügen folgende Andeutungen. Der Brennpunkt liegt in der
Brennweite f = 1⁄2 r, liegt aber hinter dem Spiegel und ist virtuell; d.
h. nach der Reflexion gehen die Strahlen so auseinander, als wenn
sie von dem hinter dem Spiegel liegenden Punkte F herkämen. In
der mathematischen Ableitung setze man den Krümmungsradius,
der diesmal die entgegengesetzte Richtung hat wie beim konkaven
Spiegel, = - r, so wird auch f negativ.
Man findet dieselbe Bildgleichung 1 = 1 + 1 , wobei aber f
f a b
negativ zu nehmen ist; tun wir dies, so ist 1 = - 1 - 1 , also b
b f a
stets negativ und dem absoluten Betrag nach kleiner als f; wenn
der leuchtende Punkt vom Unendlichen bis an den Spiegel
rückt, so befindet sich das Bild stets hinter dem Spiegel und
rückt vom Brennpunkte gegen den Spiegel; die Bilder sind
virtuell, aufrecht und verkleinert, können also von einem vor
dem Spiegel befindlichen Auge als solche wahrgenommen werden.
 Fig. 257.

Auf dieselbe Weise wie früher können die Bilder auch konstruiert
werden. (Fig. 257.) Man benützt konvexe Spiegel als kleine
To i l e t t e n s p i e g e l, da man in ihnen trotz ihres kleinen Umfangs
doch das ganze Gesicht, wenn auch verkleinert, auf einmal sehen
kann. Spiegelnde Glaskugeln in Gärten, an
Aussichtspunkten.
Aufgabe:
119. Vor einem Konvexspiegel von 20 cm Radius befindet sich
ein 5 cm hoher Gegenstand in 50 cm Entfernung. Wo liegt das Bild,
wie groß ist es, und wie groß erscheint es vom Gegenstand aus
betrachtet?

202. Brechung des Lichtes.

Brechungsgesetze.
Wenn das Licht auf die Grenzfläche
zweier Stoffe, Medien, trifft, so wird ein Teil
desselben reflektiert, d e r a n d e r e Te i l
d r i n g t i n d a s z w e i t e M e d i u m ein.
Ist dasselbe durchsichtig, so geht er im
zweiten Medium weiter. Dabei verändert er Fig. 258.
beim Übergange in das zweite Medium seine
Richtung, d. h. er wird g e b r o c h e n, erfährt eine Brechung,
Refraktion.
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