HANDBOOK OF PSYCHOLOGY

HANDBOOK OF PSYCHOLOGYVOLUME 8: CLINICAL PSYCHOLOGY

Second Edition

Volume Editors

GEORGE STRICKER AND THOMAS A. WIDIGER

Editor-in-Chief

IRVING B. WEINER

John Wiley & Sons, Inc.

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Editorial Board

Volume 1History of PsychologyDonald K. Freedheim, PhDCase Western Reserve UniversityCleveland, Ohio

Volume 2Research Methods in PsychologyJohn A. Schinka, PhDUniversity of South FloridaTampa, Florida

Wayne F. Velicer, PhDUniversity of Rhode IslandKingston, Rhode Island

Volume 3Behavioral NeuroscienceRandy J. Nelson, PhDOhio State UniversityColumbus, Ohio

Sheri J. Y. Mizumori, PhDUniversity of WashingtonSeattle, Washington

Volume 4Experimental PsychologyAlice F. Healy, PhDUniversity of ColoradoBoulder, Colorado

Robert W. Proctor, PhDPurdue UniversityWest Lafayette, Indiana

Volume 5Personality and Social PsychologyHoward Tennen, PhDUniversity of Connecticut Health CenterFarmington, Connecticut

Jerry Suls, PhDUniversity of IowaIowa City, Iowa

Volume 6Developmental PsychologyRichard M. Lerner, PhDM. Ann Easterbrooks, PhDJayanthi Mistry, PhDTufts UniversityMedford, Massachusetts

Volume 7Educational PsychologyWilliam M. Reynolds, PhDHumboldt State UniversityArcata, California

Gloria E. Miller, PhDUniversity of DenverDenver, Colorado

Volume 8Clinical PsychologyGeorge Stricker, PhDArgosy University DCArlington, Virginia

Thomas A. Widiger, PhDUniversity of KentuckyLexington, Kentucky

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vi Editorial Board

Volume 9Health PsychologyArthur M. Nezu, PhDChristine Maguth Nezu, PhDPamela A. Geller, PhDDrexel UniversityPhiladelphia, Pennsylvania

Volume 10Assessment PsychologyJohn R. Graham, PhDKent State UniversityKent, Ohio

Jack A. Naglieri, PhDUniversity of VirginiaCharlottesville, Virginia

Volume 11Forensic PsychologyRandy K. Otto, PhDUniversity of South FloridaTampa, Florida

Volume 12Industrial and Organizational

PsychologyNeal W. Schmitt, PhDMichigan State UniversityEast Lansing, Michigan

Scott Highhouse, PhDBowling Green State UniversityBowling Green, Ohio

Contents

Handbook of Psychology Preface xiIrving B. Weiner

Volume Preface xiiiGeorge Stricker and Thomas A. Widiger

Contributors xix

I PSYCHOPATHOLOGY 1

1 DIAGNOSIS AND CLASSIFICATION 3Thomas A. Widiger and Cristina Crego

2 DISORDERS OF CHILDHOOD AND ADOLESCENCE 19Eric J. Mash and David A. Wolfe

3 EATING DISORDERS: ANOREXIA NERVOSA, BULIMIA NERVOSA,AND BINGE EATING DISORDER 73Howard Steiger, Kenneth R. Bruce, and Mimi Israel

4 PERSONALITY DISORDERS 94Timothy J. Trull, Ryan W. Carpenter, and Thomas A. Widiger

5 MOOD DISORDERS 121Constance Hammen and Danielle Keenan-Miller

6 ANXIETY DISORDERS 147Kaitlin P. Gallo, Johanna Thompson-Hollands, Donna B. Pincus, and David H. Barlow

7 SEX AND GENDER IDENTITY DISORDERS 171Peggy J. Kleinplatz, Charles Moser, and Arlene Istar Lev

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8 DISORDERS OF EXTREME STRESS 193Etzel Cardena, Lisa D. Butler, Sophie Reijman, and David Spiegel

9 DISORDERS OF IMPULSE CONTROL 217Kenneth J. Sher, Rachel Winograd, and Angela M. Haeny

10 SCHIZOPHRENIA SPECTRUM CONDITIONS 240Philip D. Harvey and Christopher R. Bowie

II PSYCHOTHERAPY 263

11 PSYCHODYNAMIC PSYCHOTHERAPY 265Lawrence Josephs and Joel Weinberger

12 BEHAVIOR THERAPY AND COGNITIVE-BEHAVIORAL THERAPY 291W. Edward Craighead, Linda W. Craighead, Lorie A. Ritschel, and Alexandra Zagoloff

13 THE HUMANISTIC-EXPERIENTIAL APPROACH 320Leslie Greenberg, Robert Elliott, Germain Lietaer, and Jeanne Watson

14 PSYCHOTHERAPY INTEGRATION AND INTEGRATIVE PSYCHOTHERAPIES 345Jerry Gold and George Stricker

15 GROUP PSYCHOTHERAPIES 367William E. Piper and Carlos A. Sierra Hernandez

16 FAMILY THERAPY 384Jay Lebow and Catherine B. Stroud

17 CRISIS INTERVENTION 408Lisa M. Brown, Kathryn A. Frahm, and Bruce Bongar

18 BRIEF PSYCHOTHERAPIES 431Stanley B. Messer, William C. Sanderson, and Alan S. Gurman

19 CHILD PSYCHOTHERAPY 454Richard J. Morris, Kristin C. Thompson, and Yvonne P. Morris

20 PSYCHOTHERAPY WITH OLDER ADULTS WITHIN A FAMILY CONTEXT 474Bob G. Knight and Jennifer Kellough

21 EMPIRICALLY SUPPORTED TREATMENTS, EVIDENCE-BASED TREATMENTS,AND EVIDENCE-BASED PRACTICE 489Barry L. Duncan and Robert J. Reese

Contents ix

III PROFESSIONAL ISSUES 515

22 EDUCATION, TRAINING, LICENSING, AND CREDENTIALING IN CLINICALPSYCHOLOGY 517Judy E. Hall and Elizabeth M. Altmaier

23 ETHICAL PRACTICE IN CLINICAL PSYCHOLOGY 533Jeffrey E. Barnett and Stephen H. Behnke

24 THE U.S. HEALTH-CARE MARKETPLACE: FUTURE TENSE 558David J. Drum and Andrew C. Sekel

25 EVOLVING ROLES FOR THE PROFESSION 585Patrick H. DeLeon, Morgan T. Sammons, Sandra M. Wilkniss, Kristofer J. Hagglund, Stephen A. Ragusea,and Anthony S. Ragusea

Author Index 601

Subject Index 651

Handbook of Psychology Preface

The first edition of the 12-volume Handbook of Psychol-ogy was published in 2003 to provide a comprehensiveoverview of the current status and anticipated future direc-tions of basic and applied psychology and to serve asa reference source and textbook for the ensuing decade.With 10 years having elapsed, and psychological knowl-edge and applications continuing to expand, the time hascome for this second edition to appear. In addition to well-referenced updating of the first edition content, this secondedition of the Handbook reflects the fresh perspectives ofsome new volume editors, chapter authors, and subjectareas. However, the conceptualization and organizationof the Handbook , as stated next, remain the same.

Psychologists commonly regard their discipline as thescience of behavior, and the pursuits of behavioral scien-tists range from the natural sciences to the social sciencesand embrace a wide variety of objects of investigation.Some psychologists have more in common with biologiststhan with most other psychologists, and some have morein common with sociologists than with most of their psy-chological colleagues. Some psychologists are interestedprimarily in the behavior of animals, some in the behav-ior of people, and others in the behavior of organizations.These and other dimensions of difference among psycho-logical scientists are matched by equal if not greater het-erogeneity among psychological practitioners, who apply avast array of methods in many different settings to achievehighly varied purposes. This 12-volume Handbook of Psy-chology captures the breadth and diversity of psychologyand encompasses interests and concerns shared by psy-chologists in all branches of the field. To this end, lead-ing national and international scholars and practitionershave collaborated to produce 301 authoritative and detailedchapters covering all fundamental facets of the discipline.

Two unifying threads run through the science of behav-ior. The first is a common history rooted in conceptualand empirical approaches to understanding the nature ofbehavior. The specific histories of all specialty areas inpsychology trace their origins to the formulations of theclassical philosophers and the early experimentalists, andappreciation for the historical evolution of psychology inall of its variations transcends identifying oneself as a par-ticular kind of psychologist. Accordingly, Volume 1 in theHandbook , again edited by Donald Freedheim, is devotedto the History of Psychology as it emerged in many areasof scientific study and applied technology.

A second unifying thread in psychology is a commit-ment to the development and utilization of research meth-ods suitable for collecting and analyzing behavioral data.With attention both to specific procedures and to theirapplication in particular settings, Volume 2, again editedby John Schinka and Wayne Velicer, addresses ResearchMethods in Psychology .

Volumes 3 through 7 of the Handbook present thesubstantive content of psychological knowledge in fiveareas of study. Volume 3, which addressed Biological Psy-chology in the first edition, has in light of developments inthe field been retitled in the second edition to cover Behav-ioral Neuroscience. Randy Nelson continues as editor ofthis volume and is joined by Sheri Mizumori as a new co-editor. Volume 4 concerns Experimental Psychology andis again edited by Alice Healy and Robert Proctor. Volume5 on Personality and Social Psychology has been reorga-nized by two new co-editors, Howard Tennen and JerrySuls. Volume 6 on Developmental Psychology is againedited by Richard Lerner, Ann Easterbrooks, and Jayan-thi Mistry. William Reynolds and Gloria Miller continueas co-editors of Volume 7 on Educational Psychology .

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Volumes 8 through 12 address the application of psy-chological knowledge in five broad areas of professionalpractice. Thomas Widiger and George Stricker continue asco-editors of Volume 8 on Clinical Psychology . Volume 9on Health Psychology is again co-edited by Arthur Nezu,Christine Nezu, and Pamela Geller. Continuing to co-editVolume 10 on Assessment Psychology are John Grahamand Jack Naglieri. Randy Otto joins the Editorial Boardas the new editor of Volume 11 on Forensic Psychology .Also joining the Editorial Board are two new co-editors,Neal Schmitt and Scott Highhouse, who have reorganizedVolume 12 on Industrial and Organizational Psychology .

The Handbook of Psychology was prepared to educateand inform readers about the present state of psychologicalknowledge and about anticipated advances in behavioralscience research and practice. To this end, the Handbookvolumes address the needs and interests of three groups.First, for graduate students in behavioral science, the vol-umes provide advanced instruction in the basic conceptsand methods that define the fields they cover, togetherwith a review of current knowledge, core literature, andlikely future directions. Second, in addition to serving asgraduate textbooks, the volumes offer professional psy-chologists an opportunity to read and contemplate theviews of distinguished colleagues concerning the cen-tral thrusts of research and the leading edges of practice

in their respective fields. Third, for psychologists seek-ing to become conversant with fields outside their ownspecialty and for persons outside of psychology seekinginformation about psychological matters, the Handbookvolumes serve as a reference source for expanding theirknowledge and directing them to additional sources inthe literature.

The preparation of this Handbook was made possibleby the diligence and scholarly sophistication of 24 vol-ume editors and co-editors who constituted the EditorialBoard. As Editor-in-Chief, I want to thank each of thesecolleagues for the pleasure of their collaboration in thisproject. I compliment them for having recruited an out-standing cast of contributors to their volumes and thenworking closely with these authors to achieve chaptersthat will stand each in their own right as valuable con-tributions to the literature. Finally, I would like to thankBrittany White for her exemplary work as my adminis-trator for our manuscript management system, and theeditorial staff of John Wiley & Sons for encouraging andhelping bring to fruition this second edition of the Hand-book , particularly Patricia Rossi, Executive Editor, andKara Borbely, Editorial Program Coordinator.

Irving B. WeinerTampa, Florida

Volume Preface

This eighth volume of the Handbook of Psychology isdevoted to the primary concerns of clinical psychologistswith understanding mental, emotional, and behavioral dis-orders; with developing and applying psychological tech-niques for alleviating these disorders; and with issues ofimportance to the profession of clinical psychology. Weprovide in this second edition of our volume an updatedpresentation of what is currently known about the ori-gins, characteristics, and treatment of psychopathology, aswell as likely future advances in this knowledge. The first10 chapters address the diagnosis, etiology, course, andpathology of the major psychological disorders; the next11 chapters describe psychotherapeutic approaches com-monly used in treating these disorders; and the concludingfour chapters discuss several key professional issues inclinical psychology. It should be noted that there are nochapters dealing with assessment, which is a core compo-nent of clinical psychology, because psychological assess-ment is covered extensively in Volume 10 of the Handbook(Assessment Psychology). Similarly, each of the chaptersin the present volume incorporates attention to research andhistorical developments, but there is no separate chapter onclinical research methods, which are discussed in Volume 2of the Handbook (Research Methods in Psychology), oron the history of clinical psychology, which is reviewedin Volume 1 (History of Psychology).

The first chapter, by Thomas A. Widiger and CristinaCrego, is devoted to the classification and diagnosis of psy-chopathology. As they indicate, a common language fordescribing the problems of the mind is necessary in clin-ical research and practice. The predominant taxonomy ofpsychopathology is provided by the American PsychiatricAssociation’s (2000) Diagnostic and Statistical Manual ofMental Disorders, Fourth Edition, Text Revision (DSM-IV-TR). There is much to applaud with respect to the value,utility, and validity of this diagnostic manual, but there is

also much that is potentially quite problematic. An updatedversion of this chapter is particularly timely given that theAmerican Psychiatric Association is currently revising itsmanual (to become DSM-5 ). The process and content ofthis effort has been relatively controversial.

Eric J. Mash and David A. Wolfe follow with anupdated version of their chapter on the major domainsof child psychopathology. Beginning with disorders ofchildhood is an obvious starting point for understand-ing the development of psychopathology. However, asindicated by Mash and Wolfe, current knowledge of disor-ders of childhood and adolescence are hindered by a lackof child-specific developmental theories, and the inher-ent conceptual and research complexities associated withstudying children, which may explain why there are fewerevidence based treatments for children than for adults.Despite these caveats, tremendous advances have beenmade over the last decade. New conceptual frameworksand research methods have greatly enhanced our under-standing of childhood disorders, as well as our ability tohelp children with these problems. Also noteworthy hasbeen an increase in interdisciplinary research and integra-tion of science into clinical practice. All of these advancesare articulated within this updated version.

Eating disorders were classified as a disorder of child-hood and adolescence in earlier diagnostic nomenclatures,but it is now recognized that they can have an onset intoadulthood. Eating disorders have been recognized since thebeginning of medicine and are among the more frequentlydiagnosed and treated mental disorders. Howard Steiger,Kenneth R. Bruce, and Mimi Bruce update their chapter oneating disorders. They had included not only anorexia ner-vosa and bulimia within the original version of this chapter,but also binge eating disorder, which appears likely tobe approved for inclusion within DSM-5 . They providein their chapter a compelling integrative conceptualization

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that considers developmental, cognitive, social, dynamic,and neurophysiological contributions to the etiology andpathology of eating disorders.

Personality disorders were placed on a separate, distinctaxis for diagnosis in the third edition of the DSM-IV-TR(American Psychiatric Association, 2000) in recognitionof their prevalence and their contribution to the courseand treatment of other mental disorders. Timothy J. Trull,Ryan J. Carpenter, and Thomas A. Widiger cover in theirchapter not only what is largely known and understoodregarding disorders of personality but also the controver-sies that bedevil this section of the diagnostic manual. Anupdated version of this chapter is very timely given themajor changes that have been proposed and are likely tooccur with DSM-5, including the deletion of up to halfof the diagnoses and a shift toward a dimensional modelof classification that they had recommended in the firstedition of this book.

Mood and anxiety disorders are the most frequentmental disorders and are probably the most frequentlytreated by clinical psychologists. As suggested by Con-stance Hammen and Danielle Keenan-Miller, depressivedisorders are so ubiquitous that they have been called thecommon cold of psychological disorders. However, Ham-men documents well in her thoroughly updated chapterthat prevalence does not imply simplicity, and she againemphasizes the importance of considering etiology andpathology from divergent perspectives, including the cog-nitive, interpersonal, developmental, and neurobiological.

Kaitlin P. Gallo, Johanna Thompson-Hollands, DonnaB. Pincus, and David H. Barlow provide a comparablysophisticated overview of the etiology, development, andpathology of the many variations of anxiety disorder. Theyreview in particular separation anxiety disorder, obsessive-compulsive disorder, specific phobias, panic disorder withand without agoraphobia, and generalized anxiety disorder,indicating what is unique to each of them but empha-sizing as well the importance of recognizing what mayin fact be common to them all. These authors providea very thorough life span developmental understanding,again representing well divergent perspectives within anintegrative conceptualization.

Regrettably, the prior edition of this text did not includea chapter on sex and gender identity disorders. This gap incoverage is filled very well by the next chapter providedby Peggy J. Kleinplatz and Charles Moser, covering sex-ual dysfunctions, paraphilias, and gender identity issues.They consider psychological, interpersonal, psychosocial,and medical contributions to the etiology and pathologyof sexual dysfunctions. They cover ongoing controversies

surrounding the paraphilias, such as the need to distin-guish between normophilic and paraphilic interactions.They consider a number of controversies surroundingDSM-5, such as the emergence of a transgender commu-nity’s reaction to diagnostic labeling.

The next two chapters separated themselves somewhatfrom DSM-IV-TR, but in the end appear to have been quiteprescient. Etzel Cardena, Lisa D. Butler, Sophie Reijman,and David Spiegel again call for a section of the manualdevoted to disorders of extreme stress that would includeconditions currently classified in different sections of thediagnostic manual. This proposal received formal approvalfor consideration in DSM-5. In the end, it might not beapproved at all (and is unlikely to be approved in a man-ner entirely consistent with the suggestions of Cardenaand colleagues), but it is evident that these authors are onthe cutting edge of this area of psychopathology. Thereis perhaps much to appreciate and understand through theintegrative conceptualization of the dissociative, posttrau-matic stress, acute stress, and conversion disorders withinone common section of the diagnostic manual.

In an analogous albeit different theoretical perspective,Kenneth J. Sher, Rachel Winograd, and Angela Haeny pro-vide an integrative review of disorders of impulse dyscon-trol. They covered within the prior version of this chapterpathological gambling as well as alcohol and drug usage.Their updated version of this chapter is again quite timely,as a formal proposal for DSM-5 is to shift substance usedisorders and pathological gambling into a new sectionof the diagnostic manual for behavior addictions. Sherand colleagues provide again the empirical and conceptualsupport for this major revision to the diagnosis and con-ceptualization of substance use disorders and pathologicalgambling.

The final chapter by Philip D. Harvey and Christo-pher R. Bowie covers a variety of disorders includedwithin a common spectrum of schizophrenia-related dys-function. For example, one of the major proposals forDSM-5 is to shift schizotypal personality disorder outof the personality disorders and into a new section ofschizophrenia-spectrum disorders that Harvey and Bowieeloquently conceptualize. They also indicate how phar-macological interventions have met with limited success,whereas cognitive remediation interventions have madeconsiderable strides in the past decade. Like many otherdomains of research and treatment, advances in mappingthe human genome and understanding the complexities ofinheritance of behavioral traits have improved the under-standing of schizophrenia. The future of research andtreatment in schizophrenia spectrum conditions will likely

Volume Preface xv

include advances in understanding the neuroscience ofsocial behavior and social cognition, as well as developingcombination therapies employing psychosocial/behavioralinterventions and pharmacotherapy.

Following the description of the range of psychopathol-ogy in Part I, the volume then moves into an accountof the treatment of those disorders in Part II, whichbegins with three chapters that describe the major orienta-tions toward psychotherapy—psychodynamic, cognitive-behavioral, and humanistic—and adds an account of anexciting new development that transcends single schools:psychotherapy integration.

The first chapter in Part II covers the oldest of the sin-gle schools of psychotherapy, psychodynamic psychother-apy, and it is described thoroughly and well by LarryJosephs and Joel Weinberger. Psychodynamic psychother-apy is not limited to the work of Freud; and although thecontributions of the founder are described thoroughly, soare more recent developments in British object relationsand American interpersonal theories, the self psychologymovement, and contemporary intersubjective and rela-tional theories. The research that supports much of thiswork also is described.

The primary single school alternative to psychodynamicpsychotherapy is behavioral and cognitive-behavioral psy-chotherapy, and this is presented thoroughly and well byW. Edward Craighead, Linda Craighead, Lorie Ritschel,and Alexandra Zagoloff. This, too, is not a simple andunitary approach, but combines both behavior therapy andcognitive-behavioral psychotherapy, each of which hasmany variations. The clinical approach is integrated inthe presentation with extensive research evidence, and thedescription of specific treatments for specific syndromescan be read in conjunction with many of the chaptersin Part I that describe these syndromes in more detail.Along with psychodynamic psychotherapy and behavioraland cognitive-behavioral psychotherapy, there always hasbeen a third force, the humanistic-experiential school. Thisis covered by Leslie Greenberg, Robert Elliott, GermainLietaer, and Jeanne Watson and it also incorporates manyindividual approaches within the generic orientation, suchas person-centered, Gestalt, existential, and experientialtherapy. They all share a commitment to a phenomenolog-ical approach, a belief in the uniquely human capacity forreflective consciousness and growth, and a positive viewof human functioning. Here, as in all the psychotherapychapters, research evidence also is covered.

The fourth chapter that deals with individual psy-chotherapy does not recognize the boundaries establishedby schools, which themselves, as we have seen, are more

heterogeneous than is commonly believed. Rather, psy-chotherapy integration seeks to take from each that whichis most useful, and these attempts are described by JerryGold and George Stricker. Just as the single schoolsare more complex than initially appears to be the case,psychotherapy integration is made up of many differentattempts at rapprochement, drawing freely from all othertheoretical and technical approaches and from researchevidence. It is interesting to note that many of the lead-ing practitioners of individual schools, including most ofthe authors of the chapters presenting those schools, areinvolved in attempts at a higher order integration of theirwork, which should work for the benefit of the patientsthat are served.

Aside from the individual approaches to psychother-apy, two other modalities are quite prominent. Patients areseen not only as individuals but also in groups or alongwith other members of their family. Group psychotherapyis described by William Piper and Carlos Sierra. The goalsof group therapy vary from overall personality reorgani-zation to symptom-focused work and deal with patientsin outpatient and inpatient settings. There also is a gamutof theoretical approaches that parallel the approaches thathave been described in the chapters covering individualorientations to psychotherapy.

Family therapy is covered by Jay Lebow and Cather-ine Stroud. Although an understanding of family sys-tems theory is necessary for this work, the variations inapplication are every bit as great as in individual andgroup psychotherapy, if not greater. Many approaches tofamily therapy are becoming integrative, consistent withthe reports of an earlier chapter. Alongside the typicalapproaches to psychotherapy, specific attention is given toculturally competent family therapy and gender-sensitiveapproaches to family therapy.

Two very popular approaches that represent applica-tions of psychotherapy in specific situations or formatsare crisis intervention therapy and brief psychotherapy.Crisis intervention is the focus of the chapter by Lisa M.Brown, Kathryn Frahm, and Bruce Bongar. Crisis inter-vention involves the provision of emergency mental healthcare to individuals and groups. Crises can refer to unusualand devastating events or to milestones in human life.Examples are given concerning care to suicidal patients,survivors of disaster, and patients and families strugglingwith debilitating illness. The immediate response to thesecrises can be of great help to the victim and also can pro-vide the opportunity for much human growth. Culturalconsiderations, current research, and issues in workingwith mental health teams are reviewed, along with the

xvi Volume Preface

many theoretical approaches that are taken to resolvingcrises.

The brief psychotherapies are presented by Stanley B.Messer, William C. Sanderson, and Alan S. Gurman. Briefversions of each of the major orientations, including psy-chotherapy integration, are described, and a brief approachto marital and family psychotherapy is also covered. Itmay be a reflection of the current health-care scene thatthere is more attention given to working in a more abbre-viated fashion, but this is not necessarily second best, andthe chapter makes clear how much good work can be donein a shorter time frame than is customarily considered.

Up to this point every chapter has focused on the adultpopulation. However, in a life span framework, the otherends of the chronological spectrum also must be consid-ered. Child psychotherapy is described by Richard J. Mor-ris, Kristin Thompson, and Yvonne P. Morris. Althoughthe title is narrow, the conception includes adolescents aswell as children, and the approaches cover the usual spec-trum ranging from psychodynamic to cognitive-behavioralto humanistic approaches. Given the formative importanceof early experience, the treatment of younger people is animportant contribution to the mental health of the popu-lation, and this chapter covers the various indications andapproaches.

At the other end of the age spectrum, the approaches totreating the older patient are presented by Bob G. Knightand Jennifer Kellough. They adopt an integrative model,drawing on the usual approaches to individual treatmentand adopting methods, where necessary, to the needs ofthe older adult. The chapter uses Knight’s ContextualAdult Life Span Theory for Adapting Psychotherapy toguide the consideration of ways in which the treatment ofolder adults differs from treatment of younger adults.

Finally, Part II concludes with a chapter on Evidence-based practice by Barry Duncan and Robert J. Reese. Thisis an area of enormous current interest, and the authorscover a controversial area by giving attention to all of therequirements involved for true evidence-based practiceto take place. A critical distinction between evidence-based practice and empirically supported techniquesis made.

In each of the chapters in Part II, concerned as theyall are with psychotherapy, the picture arises of a fieldmarked by great heterogeneity. The value of integrationis presented, either in a specific chapter devoted to psy-chotherapy integration or as incorporated in many otherchapters that deal with specific populations or modalities.Each chapter presents evidence for the approach being pre-sented, and the picture of an evolving and developing field,

marked by great promise and great accomplishment, isclear.

Clinical psychology is a science and a practice, andboth elements have been presented consistently through-out the first two parts. It also is a profession, and issuesthat concern the profession are the topic of Part III. It isnot sufficient for an individual to declare himself to bea clinical psychologist; rather, much training is required,and credentials are necessary so that members of the pub-lic who wish to use the service of professional psychol-ogists can be well-informed and well-served. Concernsabout the education, training, licensing, and credential-ing of clinical psychologists are presented by Judy E.Hall and Elizabeth M. Altmaier. They cover these issuesas manifested in the United States, Canada, and also inLatin America and the European Union. They also addressthe recent emphasis on mobility and the comparability oftraining and credentials in a context of accountability.

A profession must be self-regulating and serve theinterests of the public if it is to be established and accepted.One necessary component of self-regulation is ethicalpractice, and issues about ethics that relate to clinicalpsychology are described by Jeffrey Barnett and StephenBehnke. The APA ethics code is generic and applies toall psychologists, but this chapter focuses on those issuesthat are of most concern to the clinical psychologist. Theseinclude major ethical practice issues and frequent problemsexperienced by practitioners. Familiarity with these issuesand their successful resolution are necessary for the soundpractitioner, and this presentation should help to focus thepotential problem areas and the models of understandingand resolving them.

Clinical psychology is practiced in a social context,and the changing context has had a marked effect on thenature of the practice. The health-care marketplace in theUnited States is described by David J. Drum and AndrewSekel. Their survey is both historical and conceptual, andit traces the evolution of health care in the United Statesfrom its early stage of self-regulation and independenceto the current stage of input from multiple stakeholdersin health-care delivery. The implication this has for thefuture is not clear, of course, but some very educatedguesses are offered, as well as the identification of keyareas of concern.

Finally, we turn our attention to the future. Patrick H.DeLeon, Morgan Sammons, Sandra Wilkniss, KristoferHagglund, Stephen Ragusea, and Anthony Raguseaexplore areas of expanding roles for psychologists infuture years. They discuss the impact of the new health-care legislation and other cutting-edge areas such as

Volume Preface xvii

primary care practice, telehealth, public health, andprescriptive authority and policy opportunities. As oursociety evolves, the field of clinical psychology also mustevolve, and these authors lay out many possibilities forgrowth and development.

Clinical psychology is an expanding science and pro-fession, and its capacity to continue to be relevant dependson its ability to adapt to changing social conditions, needs,and opportunities. We began with an account of histori-cal factors, attempted to provide a context for the currentstate of the field, presented chapters that described thesedevelopments in detail, and concluded with a look towardthe future. Clinical psychology has made major contribu-tions to the discipline of psychology and to the welfareof society, and it shows every indication of continuing togrow and evolve with the world about it, and, by doingso, to retain its position at the forefront of scientific andprofessional developments. We hope that we have been

successful in outlining these possibilities and that we willbe witness to continued growth and development.

George Stricker

Thomas A. Widiger

REFERENCES

American Psychiatric Association. (2000). Diagnostic and statisticalmanual of mental disorders (4th ed., Text Revision). Washington,DC: Author.

Benjamin, L. T. (1996). Lightner Witmer’s legacy to American psychol-ogy. American Psychologist, 51, 235–236.

Hilgard, E. R. (1987). Psychology in America: A historical survey . NewYork, NY: Harcourt Brace Jovanovich.

Murray, H. A. (1956). Morton Prince. Journal of Abnormal Psychology,52, 291–295.

Witmer, L. (1907). Clinical psychology. The Psychological Clinic, 1,1–9.

Contributors

Elizabeth M. Altmaier, PhDDepartment of Psychological

and Quantitative FoundationsUniversity of IowaIowa City, IA

David H. Barlow, PhD, ABPPDepartment of PsychologyBoston UniversityBoston, MA

Jeffrey E. Barnett, PsyD, ABPPDepartment of PsychologyLoyola University MarylandBaltimore, MD

Stephen H. Behnke, JD, PhDAmerican Psychological Association Ethics Office750 First Street, NEWashington, DC 20002

Bruce Bongar, PhD, ABPPPalo Alto UniversityPalo Alto, CAandDepartment of Psychiatry and Behavioral SciencesStanford University School of MedicineStanford, CA

Christopher R. Bowie, PhDDepartments of Psychology and PsychiatryQueen’s UniversityKingston, Ontario, Canada

Lisa M. Brown, PhDSchool of Aging StudiesCollege of Behavioral and Community SciencesUniversity of South FloridaTampa, FL

Kenneth R. Bruce, PhDEating Disorders ProgramDouglas HospitalDepartment of PsychiatryMcGill UniversityMontreal, Quebec, Canada

Lisa D. Butler, PhDSchool of Social WorkState University of New YorkBuffalo, NY

Etzel Cardena, PhDDepartment of PsychologyLund UniversityLund, Sweden

Ryan J. Carpenter, BADepartment of Psychological ScienceUniversity of MissouriColumbia, MO

Linda W. Craighead, PhDDepartment of PsychologyEmory UniversityAtlanta, GA

W. Edward Craighead, PhDDepartment of Psychiatry

and Behavioral SciencesDepartment of PsychologyEmory UniversityAtlanta, GA

Cristina Crego, BADepartment of PsychologyUniversity of KentuckyLexington, KY

xix

xx Contributors

Patrick H. DeLeon, PhDFormer APA President

David J Drum, PhD, ABPPDepartment of Educational PsychologyUniversity of TexasAustin, TX 78712

Barry Duncan, PsyDThe Heart and Soul of Change ProjectJensen Beach, FL

Robert Elliott, PhDSchool of Psychological Sciences and HealthUniversity of StrathclydeGlasgow, ScotlandUK

Kathryn A. Frahm, PhDSchool of Aging StudiesUniversity of South FloridaTampa, FL

Kaitlin P. Gallo, MADepartment of PsychologyBoston UniversityBoston, MA

Jerry Gold, PhD, ABPPDerner Institute of Advanced Psychological StudiesAdelphi UniversityGarden City, NY

Leslie S. Greenberg PhDDepartment of PsychologyYork University4700 Keele St.Toronto, ON, Canada

Alan S. Gurman, PhDThe Family Institute at Northwestern UniversityEvanston, ILandClinical Psychology Doctoral ProgramUniversity of WisconsinMadison, WI

Angela Haeny, MADepartment of Psychological ScienceUniversity of MissouriColumbia, MO

Kristofer J. Hagglund, PhDSchool of Health Professions and MPH ProgramUniversity of MissouriColumbia, MO

Judy E. Hall, PhDExecutive OfficerNational Register of Health Service

Providers in PsychologyWashington, DC

Constance Hammen, PhDDepartment of PsychologyUniversity of CaliforniaLos Angeles, CA

Philip D. Harvey, PhDDepartment of Psychiatry

and Behavioral SciencesUniversity of Miami Miller

School of MedicineMiami, FL

Mimi Israel, MDEating Disorders ProgramDouglas HospitalDepartment of PsychiatryMcGill UniversityMontreal, Quebec, Canada

Lawrence Josephs, PhDDerner Institute of Advanced Psychological StudiesAdelphi UniversityGarden City, NY

Danielle Keenan-Miller, PhDDepartment of PsychologyUniversity of Southern CaliforniaLos Angeles, CA

Jennifer L. Kellough, MADepartment of PsychologyUniversity of Southern CaliforniaLos Angeles, CA

Peggy J. Kleinplatz, PhDDepartment of PsychiatryUniversity of OttawaOttawa, Ontario, Canada

Contributors xxi

Bob G. Knight, PhDDavis School of Gerontology

and Department of PsychologyUniversity of Southern CaliforniaLos Angeles, CA

Jay L. Lebow, PhD, ABPPFamily Institute at Northwestern UniversityEvanston IL

Arlene Istar Lev, LCSW-R, CASACSchool of Social WelfareUniversity at AlbanyAlbany, NY

Germain Lietaer, PhDDepartment of Clinical PsychologyCatholic University LeuvenLeuven, Belgium

Eric J. Mash, PhDDepartment of PsychologyUniversity of CalgaryCalgary, Alberta, Canada

Stanley B. Messer, PhDGraduate School of Applied and

Professional PsychologyRutgers UniversityPiscataway, NJ

Richard J. Morris, PhDSchool Psychology ProgramUniversity of ArizonaCollege of EducationTucson, AZ

Yvonne P. Morris, PhDPrivate PracticeTucson, AZ

Charles Moser, MD, PhDDepartment of Sexual MedicineInstitute for Advanced Study of Human SexualitySan Francisco, CA

Donna B. Pincus, PhDDepartment of PsychologyBoston UniversityBoston, MA

William E. Piper, PhDDepartment of PsychiatryThe University of British ColumbiaVancouver, BC

Anthony S. Ragusea, PsyDPrivate PracticeKey West, FL

Stephen A. Ragusea, PsyDPrivate PracticeKey West, FL

Robert J. Reese, PhDDepartment of Educational, School,

& Counseling PsychologyUniversity of KentuckyLexington, KY

Sophie Reijman, BScChild and Family StudiesLeiden UniversityLeiden, The Netherlands

Lorie A. Ritschel, PhDDepartment of Psychiatry and Behavioral SciencesEmory University School of MedicineAtlanta, GA

Morgan T. Sammons, PhD, ABPPCalifornia School of Professional PsychologySan Francisco, CA

William C. Sanderson, PhDDepartment of PsychologyHofstra UniversityHempstead, NY 11549

Andrew Sekel, PhDChief Executive OfficerOptumHealth Behavioral SolutionsSan Francisco, CA

Kenneth J. Sher, PhDDepartment of Psychological ScienceUniversity of MissouriColumbia, MO

xxii Contributors

Carlos A. Sierra Hernandez, BADepartment of PsychiatryThe University of British ColumbiaVancouver, BC

David Spiegel, MDDepartment of Psychiatry

and Behavioral SciencesStanford UniversityStanford, CA

Howard Steiger, PhDEating Disorders ProgramDouglas HospitalDepartment of PsychiatryMcGill UniversityMontreal, Quebec, Canada

George Stricker, PhD, ABPPDept. of Clinical PsychologyAmerican School of Professional Psychology

at Argosy University, Washington DCArlington, VA 22209

Catherine Stroud, PhDDepartment of PsychologyWilliams CollegeWilliamstown, MA 01267

Kristin C. Thompson, PhDSchool Psychology ProgramUniversity of ArizonaCollege of EducationTucson, AZ 85721

Johanna Thompson-Hollands, MADepartment of PsychologyBoston UniversityBoston, Massachusetts

Timothy J. Trull, PhDDepartment of Psychological ScienceUniversity of Missouri,Columbia, Missouri

Jeanne Watson, PhDDept. of Adult Education

and Counselling PsychologyUniversity of Toronto, TorontoCanada, M5S 1V6

Joel Weinberger, PhDDerner Institute of Advanced

Psychological StudiesAdelphi University, Garden City, NYGarden City, NY 11530

Thomas A Widiger, PhDDepartment of PsychologyUniversity of KentuckyLexington, Kentucky

Sandra M. Wilkniss, PhDAPA/AAAS Congressional FellowArlington, VA 22205

Rachel Winograd, MADepartment of Psychological ScienceUniversity of Missouri,Columbia, Missouri

David A. Wolfe, PhDCenter for Addiction and Mental HealthUniversity of TorontoToronto, Ontario, Canada

Alexandra Zagoloff, PhDDepartment of Psychiatry

and Behavioral SciencesEmory UniversityAtlanta, GA 30306

PART I

Psychopathology

CHAPTER 1

Diagnosis and Classification

THOMAS A. WIDIGER AND CRISTINA CREGO

HISTORICAL BACKGROUND 3CONTINUING ISSUES FOR ICD-11 AND DSM-5 7

CONCLUSIONS 15REFERENCES 15

Human beings engage in a wide array of behaviors, includ-ing eating, sleeping, talking, feeling, thinking, playing,buying, and having sex. All of these forms of behav-ior include a maladaptive variant that is diagnosed as amental disorder by the American Psychiatric Association.Dysfunctional, aberrant, and maladaptive feeling, think-ing, behaving, and relating to others are of substantialconcern to many different professions, the members ofwhich hold an equally diverse array of opinions regard-ing etiology, pathology, and treatment. It is imperative thatthese persons be able to communicate meaningfully withone another. The primary purpose of an official diagnos-tic nomenclature is to provide this common language ofcommunication (Kendell, 1975; Sartorius et al., 1993).

An official diagnostic nomenclature, however, canbe an exceedingly powerful document, impacting manyimportant social, forensic, clinical, and other professionaldecisions (Schwartz & Wiggins, 2002). Persons think interms of their language and the predominant languagesof psychopathology are the fourth edition of the Amer-ican Psychiatric Association’s (1994, 2000) Diagnosticand Statistical Manual of Mental Disorders (DSM-IV-TR)and the 10th edition of the World Health Organization’s(WHO) International Classification of Diseases (ICD-10 ;WHO, 1992). As such, these nomenclatures have a sub-stantial impact on how clinicians, social agencies, thegovernment, and the general public conceptualize aber-rant, problematic, and maladaptive behavior.

Interpreting DSM-IV-TR or ICD-10 as conclusively val-idated nomenclatures, however, exaggerates the extent oftheir scientific support (Frances, Pincus, Widiger, Davis,& First, 1990; Frances & Widiger, in press). There is lit-tle within DSM-IV-TR or ICD-10 that is not subject to

significant dispute. Mental disorders are to a substantialextent constructions of clinicians and researchers ratherthan proven, evident diseases or illnesses (Maddux, Gos-selin, & Winstead, 2008). On the other hand, the diag-noses contained within DSM-IV-TR and ICD-10 are notnecessarily lacking in credible or compelling empiricalsupport. DSM-IV-TR and ICD-10 contain many flaws, butthey are also well-reasoned, scientifically researched, and,for the most part, well-documented nomenclatures thatdescribe what is currently understood by most scientists,theorists, researchers, and clinicians to be the predomi-nant forms of psychopathology (Widiger, in press). Thischapter overviews the DSM-IV-TR diagnostic nomencla-ture, beginning with historical background, followed bya discussion of the major issues facing the forthcomingDSM-5 and future revisions.

HISTORICAL BACKGROUND

The impetus for the development of an official diagnosticnomenclature was the chaos and confusion generated byits absence (Widiger, 2001). “For a long time confusionreigned. Every self-respecting alienist [the 19th-centuryterm for a psychiatrist], and certainly every professor, hadhis own classification” (Kendell, 1975, p. 87). For theyoung, aspiring professor, the production of a new systemfor classifying psychopathology was a standard rite of pas-sage in the 19th century.

To produce a well-ordered classification almost seems to havebecome the unspoken ambition of every psychiatrist of indus-try and promise, as it is the ambition of a good tenor to strikea high C. This classificatory ambition was so conspicuous that

3

4 Psychopathology

the composer Berlioz was prompted to remark that after theirstudies have been completed a rhetorician writes a tragedyand a psychiatrist a classification. (Zilboorg, 1941, p. 450)

In 1908, the American Bureau of the Census askedthe American Medico-Psychological Association (whichsubsequently altered its title in 1921 to the AmericanPsychiatric Association) to develop a standard nosologyto facilitate the obtainment of national statistics:

The present condition with respect to the classification ofmental diseases is chaotic. Some states use no well-definedclassification. In others the classifications used are similar inmany respects but differ enough to prevent accurate com-parisons. Some states have adopted a uniform system, whileothers leave the matter entirely to the individual hospitals.This condition of affairs discredits the science. (Salmon,Copp, May, Abbot, & Cotton, 1917, pp. 255–256)

The American Medico-Psychological Association, incollaboration with the National Committee for MentalHygiene, issued a nosology in 1918, titled Statistical Man-ual for the Use of Institutions for the Insane (Menninger,1963). This nomenclature, however, failed to obtain wideacceptance. It included only 22 diagnoses and these wereconfined largely to psychoses with a presumably neu-robiological pathology. Therefore, “in the late twenties,each large teaching center employed a system of its ownorigination, no one of which met more than the immedi-ate needs of the local institution” (American PsychiatricAssociation, 1952, p. v). There was no common, unifiedsystem of diagnosis. Patients being treated at one clinicwere given different diagnoses than patients treated atanother clinic. Consistent, accumulative research was dif-ficult to produce as each researcher studied his or her ownconstructions, rarely building upon a common scientificbase. A conference was held at the New York Academy ofMedicine in 1928 to develop a more authoritative and uni-formly accepted manual. The resulting nomenclature wasmodeled after the Statistical Manual but it was distributedto hospitals within the American Medical Association’sStandard Classified Nomenclature of Disease. Many hos-pitals used this system but it eventually proved to be inad-equate when the attention of the profession expanded wellbeyond psychotic disorders during World War II. ICD-6and DSM-I

The Navy, Army, and Veterans Administration devel-oped their own, largely independent nomenclatures duringWorld War II due in large part to the inadequacies ofthe Standard Classified . “Military psychiatrists, inductionstation psychiatrists, and Veterans Administration psychi-atrists, found themselves operating within the limits of

a nomenclature specifically not designed for 90% of thecases handled” (American Psychiatric Association, 1952,p. vi). The World Health Organization (WHO) acceptedthe authority in 1948 to produce the sixth edition ofthe International Statistical Classification of Diseases,Injuries, and Causes of Death (ICD). ICD-6 was the firstedition to include a section devoted to mental disorders(Kendell, 1975), perhaps in recognition of the many psy-chological casualties of World War II, as well as theincreasing impact and contribution of mental health pro-fessions within the broader society. The United StatesPublic Health Service commissioned a committee, chairedby the psychiatrist George Raines (notably though withrepresentations from a variety of other professions andpublic health agencies) to develop a variant of the men-tal disorders section of ICD-6 for use within the UnitedStates. The United States, as a member of the WHO, wasobliged to use ICD-6 , but adjustments could be madeto maximize the acceptance and utility of ICD-6 withinthe United States. The resulting nomenclature resembledclosely the Veterans Administration system developed byBrigadier General William Menninger (brother to KarlMenninger, 1963). Responsibility for publishing and dis-tributing this nosology was given to the American Psy-chiatric Association (1952) under the title Diagnostic andStatistical Manual: Mental Disorders (hereafter referredto as DSM-I ).

DSM-I was generally successful in obtaining accep-tance, due in large part to its expanded coverage, par-ticularly the inclusion of somatoform disorders, stressreactions, and personality disorders. DSM-I also includednarrative descriptions of each disorder to facilitate under-standing and more consistent applications. Nevertheless,fundamental criticisms regarding the reliability and valid-ity of psychiatric diagnosis were also being raised (e.g.,Scheff, 1966; Szasz, 1960; Zigler & Phillips, 1961). Forexample, a widely cited reliability study by Ward, Beck,Mendelson, Mock, and Erbaugh (1962) concluded thatmost of the poor agreement among psychiatrists’ diag-noses was due largely to inadequacies of DSM-I , and morespecifically, its failure to provide specific, explicit guide-lines as to the diagnostic criteria for each respective disor-der, allowing clinicians to vary widely in how they appliedthe diagnostic system.

ICD-6 was even less successful. The “mental disorderssection [of ICD-6] failed to gain [international] accep-tance and eleven years later was found to be in officialuse only in Finland, New Zealand, Peru, Thailand, and theUnited Kingdom” (Kendell, 1975, p. 91). The WHO there-fore commissioned a review by the English psychiatrist,

Diagnosis and Classification 5

Erwin Stengel. Stengel (1959) reiterated the importanceof establishing an official nomenclature.

A . . . serious obstacle to progress in psychiatry is difficulty ofcommunication. Everybody who has followed the literatureand listened to discussions concerning mental illness soondiscovers that psychiatrists, even those apparently sharing thesame basic orientation, often do not speak the same language.They either use different terms for the same concepts, orthe same term for different concepts, usually without beingaware of it. It is sometimes argued that this is inevitable inthe present state of psychiatric knowledge, but it is doubtfulwhether this is a valid excuse. (Stengel, 1959, p. 601)

Stengel (1959) attributed the failure of clinicians toaccept the mental disorders section of ICD-6 to the pres-ence of theoretical biases, cynicism regarding any psychi-atric diagnoses (some theoretical perspectives opposed theuse of any diagnostic terms), and the presence of abstract,highly inferential diagnostic criteria that hindered consis-tent, uniform applications by different clinicians.

ICD-8 and DSM-II

ICD-6 had been revised to ICD-7 in 1955 but there wereno revisions to the mental disorders section. Work beganon ICD-8 soon after Stengel’s 1959 report. The finaledition was approved by the WHO in 1966 and becameeffective in 1968. A companion glossary, in the spirit ofStengel’s (1959) recommendations, was to be publishedconjointly, but work did not begin on the glossary until1967 and it was not completed until 1972. “This delaygreatly reduced [its] usefulness, and also [its] authority”(Kendell, 1975, p. 95). In 1965, the American PsychiatricAssociation appointed a committee, chaired by Ernest M.Gruenberg, to revise DSM-I to be compatible with ICD-8and yet also be suitable for use within the United States.The final version was approved in 1967, with publicationin 1968.

The diagnosis of mental disorders, however, was con-tinuing to receive substantial criticism (e.g., Rosenhan,1973). A fundamental problem continued to be the absenceof empirical support for the reliability, let alone the valid-ity, of its diagnoses (e.g., Blashfield & Draguns, 1976).Researchers, therefore, took to heart the recommendationsof Stengel (1959) to develop more specific and explicit cri-terion sets (Blashfield, 1984). The most influential of theseefforts was produced by a group of neurobiologically ori-ented psychiatrists at Washington University in St. Louis.Their criterion sets generated so much interest that theywere published separately in what has become one of the

most widely cited papers in psychiatry (i.e., Feighner et al.,1972).

The Feighner et al. (1972) criterion sets were confinedto just the 15 disorders of primary interest to the Wash-ington University researchers. Their approach to diagnosiswas greatly expanded by Robert Spitzer (a technical con-sultant for DSM-II ; American Psychiatric Association,1968) into a manual that covered a much wider vari-ety of diagnosis, titled the Research Diagnostic Criteria(RDC; Spitzer, Endicott, & Robins, 1978). The RDC wasadopted by many research programs around the world, andcontributed to the obtainment of more consistent and repli-cable research findings. This subsequent research usingspecific and explicit criterion sets assessed with struc-tured interviews has since indicated that mental disorderscan be diagnosed reliably and do provide valid informa-tion regarding etiology, pathology, course, and treatment(Kendler, Munoz, & Murphy, 2010).

ICD-9 and DSM-III

By the time Feighner et al. (1972) was published, workwas nearing completion on ICD-9 . The authors of ICD-9had decided to include a glossary, but it was apparent thatit would not include the more specific and explicit crite-rion sets developed and used in research (Kendell, 1975).In 1974, the American Psychiatric Association appointed aTask Force, chaired by Robert Spitzer, to revise DSM-II ina manner that would be compatible with ICD-9 but wouldalso incorporate many of the advances in diagnosis cur-rently being developed. DSM-III was published in 1980and was remarkably innovative, including (a) a multiaxialdiagnostic system (most mental disorders were diagnosedon Axis I, personality and specific developmental disor-ders were diagnosed on Axis II, medical disorders onAxis III, psychosocial stressors on Axis IV, and level offunctioning on Axis V), (b) specific and explicit crite-rion sets for all but one of the disorders (i.e., schizoaf-fective), (c) a substantially expanded text discussion ofeach disorder to facilitate diagnosis (e.g., age of onset,sex ratio, course, complications, and familial pattern), and(d) removal of terms (e.g., neurosis) that appeared to favora particular theoretical model for the disorder’s etiologyor pathology (Spitzer, Williams, & Skodol, 1980).

DSM-III-R

Many of the criterion sets developed for DSM-III lackedmuch prior history or field testing. Most were constructedby work group members with little guidance as to how

6 Psychopathology

they would in fact work in general clinical practice or evenresearch settings. As a result, a number of obvious errorsoccurred (e.g., panic disorder in DSM-III could not bediagnosed in the presence of major depression). “Criteriawere not entirely clear, were inconsistent across categories,or were even contradictory” (American Psychiatric Asso-ciation, 1987, p. xvii). The American Psychiatric Associa-tion therefore authorized the development of a revision toDSM-III to make corrections and refinements. Fundamen-tal revisions were to be tabled until work began on ICD-10 . However, it might have been unrealistic to expect theauthors of DSM-III-R to confine their efforts to refinementand clarification, given the impact, success, and impor-tance of DSM-III .

The impact of DSM-III has been remarkable. Soon afterits publication, it became widely accepted in the UnitedStates as the common language of mental health cliniciansand researchers for communicating about the disorders forwhich they have professional responsibility. Recent majortextbooks of psychiatry and other textbooks that discusspsychopathology have either made extensive reference toDSM-III or largely adopted its terminology and concepts.(American Psychiatric Association, 1987, p. xviii)

Prior to DSM-III there were few psychiatrists or psy-chologists particularly interested in diagnosis and clas-sification. Subsequent to DSM-III , psychiatric diagnosisbecame a major focus of scientific research. It was notdifficult to find persons who wanted to be involved inthe development of DSM-III-R, and everyone wanted tohave a significant impact. Ironically, there were consider-ably more persons involved in DSM-III-R than in DSM-III,yet its mission was purportedly far more conservative andlimited in scope. Not surprisingly, in the end, there weremany proposals for major revisions and even new diag-noses. In fact, four of the diagnoses approved for inclusionby the authors of DSM-III-R (i.e., self-defeating personal-ity disorder, sadistic personality disorder, late luteal phasedysphoric disorder [the name for which was subsequentlychanged to premenstrual dysphoric disorder], and paraphil-iac rapism) generated so much controversy that a specialad-hoc committee was appointed by the Board of Trusteesof the American Psychiatric Association to reconsider theirinclusion. A concern common to them all was that theirinclusion might result in harm to women. For example,self-defeating personality disorder might have been usedto blame female victims for having been abused, whereassadistic personality disorder could be used to help mitigatethe criminal responsibility of the abusing spouse. Para-philiac rapism could likewise be used to mitigate crimi-nal responsibility for rape. Another concern was the lack

of sufficient empirical support to address or offset theseconcerns. A compromise was eventually reached in whichthe two personality disorders and late luteal phase dyspho-ric disorder were included in an appendix (Endicott, 2000;Widiger, 1995); paraphiliac rapism was deleted entirely.

ICD-10 and DSM-IV

Work on DSM-III-R was supposed to have been completedin 1985, but given the ever-expanding breadth of its expan-sions and revisions, by the time work was completed onDSM-III-R, work had already begun on ICD-10 . The deci-sion of the authors of DSM-III to develop an alternativeto ICD-9 (i.e., include specific and explicit criterion sets)was instrumental in developing a highly innovative manual(Kendell, 1991; Spitzer et al., 1980). However, its innova-tions were also at the cost of decreasing compatibility withthe ICD-9 nomenclature that was used throughout the restof the world, which is problematic to the stated purpose ofproviding a common language of communication. In 1988,the American Psychiatric Association appointed a DSM-IVTask Force, chaired by Allen Frances (Frances, Widiger,& Pincus, 1989). Mandates for DSM-IV included bettercoordination with ICD-10 and improved documentation ofempirical support.

The DSM-IV committee aspired to use a more conser-vative threshold for the inclusion of new diagnoses andto have decisions that were guided more explicitly by thescientific literature (Frances & Widiger, in press). Propos-als for additions, deletions, or revisions were guided byliterature reviews that were required to use a specific meta-analytic format that maximized the potential for informa-tive critical review, containing (for example) a methodsection that explicitly documented the criteria for includingand excluding studies and the process by which the litera-ture had been reviewed (Frances et al., 1989). The purposeof this structure was to make it easier to discover whetherthe author was confining his or her review only to studiesthat were consistent with a particular proposal, and fail-ing to acknowledge opposing perspectives. These reviewswere published within a three-volume DSM-IV Sourcebook(e.g., Widiger et al., 1994). Testable questions that couldbe addressed with existing data sets were also explored inadditional studies, which emphasized the aggregation ofmultiple data sets from independent researchers, and 12field trials were conducted to provide reliability and valid-ity data on proposed revisions. The primary purposes ofthe field trials were to address fundamental questions orconcerns with regard to a particular proposal, as well asto compare and contrast alternative proposals. The results