DSM-IV-TR in Action

Chapter OneGetting Started

The Bibles of Mental Health Assessment

The DSM -- Diagnostic and Statistical Manual of Mental disorders.

DSM -- 1952

DSM II -- 1968

DSM-III and DSM III-R--1980 and 1987

DSM IV and DSM IV-TR -- 1994 and 2000

The ICD -- International Classification of Diseases 10th Edition

Concerns re: the DSM

Stigma attached to labeling, exacerbated by tendency to overdiagnose for the purpose of reimbursement

Tendency to underdiagnose as a form of protection of client’s privacy, domestic defense, and job security.

Non medical providers tend to take the DSM less seriously and base diagnoses on subjective assessments rather than symptom profiles.

Concerns re: the DSM

Early efforts focused on etiology (origins) of disorders, overlooking treatment

Most of the users of the DSM-IV are non-medication providers concerned more about treatment.

The early DSM disregarded the important of the person in context, and was seen as a list of labels divorced from the person’s life situation.

Concerns re: the DSM

Gender and racial biases influenced diagnostic labels and diagnostic patterns. (See Enclycopedia entry by Dr. Sparrow)

Diagnoses were formulated in the absence of field trials and evidence-based principles.

Later editions reflected reliability studies and criteria verification.

Improvements over Time

Increasing sophistication -- from 60 to 400 categories

Errors corrected

Updating of each diagnostic category

Coordinating of the DSM and ICD

Incorporated research and lit reviews

More educational in its focus, so it can be a teaching tool.

Continuing Concerns

Practictioners tend to diagnose more severely when the using the DSM than the ICD

Categorical vs. dimensional assessments -- http://ajp.psychiatryonline.org/cgi/content/full/162/10/1919

Continuing Concerns

Labeling can leave a person with a stigma that is hard to remove, similar to someone being convicted of a felony (no provision for removing the diagnosis)

Some practitioners resist using the DSM labels for fear of social and public stigma. (E.g. pilots who are depressed are grounded, and intelligence officers can lose their security clearances.)

Certain diagnoses carry more potential stigma than others.

Continuing Concerns

Clients self-diagnosing -- “sophomore syndrome”

Clients will begin acting the part.

Others begin to expect and condone behavior because it’s part of the diagnosis.

We need to remember that we are diagnosing a disorder or illness, not labelling the person. Not “a schizophrenic,” but “a person with schizophrenia.”

The Person in Environment Classification System (PIE)

The individual is influenced by the environment (relationships, society, economics) in a reciprocal manner; that is, in a circular dynamic or feedback loop.

The PIE focuses on “units larger than the individual”

Family therapy notion is that we live in “nested systems”; person, family, community, nation, world

The Person in Environment Classification System (PIE)

The PIE changed the way that Axis 4 on the DSM is used.

originally “severity of psychosocial stressors” on a 1-5 scale

presently “psychosocial and environ. problems” with the problems actually listed!

Central Organizing Principle

Egan says that the singular goal of therapy is “to help clients manage their problems in living more effectively and develop unused or underused opportunities more fully.” (The Skilled Helper)

Any assessment or diagnosis that does not facilitate this goal is without value.

Chapter TwoBasics and Applications

The DSM is an essential starting point in determining the nature of a client’s problem.

It does not provide treatment approaches, so companion books are necessary.

It should only be used by professionals.

Multidisciplinary vs. interdisciplinary approaches

A multidisciplinary approach leaves professionals to make their own assessments, and then combine them.

Example: an LPC and a psychiatrist working with the same client to provide complementary treatment, but who do not collaborate on diagnosis and treatment plans.

Where in your current career is there a multidisciplinary approach?

Multidisciplinary vs. interdisciplinary approaches

An interdisciplinary approach is a team approach to a comprehensive assessment and treatment plan. It’s more likely to happen within an institution that employs a variety of health professionals.

Where in your current career is there a multidisciplinary approach?

Diagnosis and Assessment

Diagnosis or assessment?

Most agree that they are interchangeable, although “diagnosis” is more clearly disease-oriented, whereas “assessment” has no underlying implications.

If treated as separate, then assessment precedes diagnosis

Disease or disorder?

Disease, a known pathological process

Disorder, may include two or more diseases

Diagnosis and Assessment

Diagnosis should always relate directly to the client’s needs, and give rise to strategies for assisting the client in understanding his problem, as well as developing skills for coping with it.

Diagnosis should be considered tentative and evolving.

Diagnosis should be shared with the client, and changes made as new information and understandings develop.

Diagnosis should always be reviewed against improvements or deteriorations so that the diagnosis and the mental condition remain congruent.

Diagnosis and Assessment

Diagnostic “product” is the sum total of the information collected during the assessment.

#1 Corey

What’s happening?

What does the client want?

What is the client learning in therapy?

To what extent is the client applying what is learned?

Diagnosis and Assessment

#2 Carlton (biomedical, psychological and social)

Biomedical -- first priority

any physical disability and its impact

client ‘s view of health status

Diagnosis and Assessment

Psychological assessment

Descriptive-- give mental status exam

Is the client capable of thinking and reasoning?

Is client dangerous to self or others?

Diagnosis and Assessment

Social and environmental assessment

Is client open to help?

What community support systems are in place?

Client impaired in work environment? Is there support?

Friends and family support?

Religious or ethnic affiliation

Diagnosis and Assessment

Controversy: A diagnostic label, which supports an “illness” approach, conflicts with the values of personal will, choice and responsibility -- qualities that are central to existential, client-centered, cognitive-behavioral, systemic (family), and solution focused (competency-based) approaches.

But...if you want to survive in private practice, you need to embrace the DSM in order to meet the expectations of insurers, who only want to pay for “medically necessary” conditions.

The Diagnostic Assessment

The diagnostic assessment is a term used to combine the process of collecting information (assessment) with a diagnostic determination based on the process.

#3 Dziegielewski suggests five steps:

Examine the amount and accuracy of information shared.

Gather an accurate definition of the problem.

Take beliefs and values into consideration

Assess culture and race issues

Assess competencies and resources

Culture and EthnicitY

Culture -- sum total of life patterns passed from generation to generation, including language, religious ideals, artistic expression, and patterns of thinking and relating.

Ethnicity -- one’s roots, ancestry, and heritage--while ethnic identity is the acceptance of one’s ethnicity

Race is defined as a consciousness of status or identity based on ancestry and color

Identity

Therapy should involve assisting client in discriminating between personal identity and ascribed identity. A very big enterprise!

There is a fine line between being culturally sensitive and respectful and challenging beliefs and customs that may be causing the client distress in

the current social-cultural context, or

in the context of personal identity needs.

Age-Related Issues

Children -- Assess family of origin, if possible within the home. If not cooperative, get close to the family through intermediaries.

Elderly

Assess fears and myths, loss of sexual function, suicidal potential.

Retirement issues, chronic conditions, physical health

Depression, confusion

Assess your own attitudes toward aging. Are you afraid of getting old? Do you like elderly people? Are you close to any?

Gender-Related Issues

Assess

Gender perception, and whether client perceives gender to be significant in beliefs and values

Traditional roots and attitudes toward gender

Adaptive and maladaptive behaviors related to gender

Environmental and relationship factors

Family attitudes and perceptions

Gender-Related Issues

Also assess practitioner gender-related issues: Is the therapist sensitive to:

The fact that individuals are products of social and family context?

His or her own internal gender assumptions?

The need to be tolerant to individual uniqueness and deviance?

How gender can influence the diagnostic assessment?

Subtypes and Course specifiers

The first three digits of the DSM code are the diagnosis

The fourth and fifth digits are used for subtypes and specifiers

Think of the fourth and fifth digits as a way to further describe and differentiate a major diagnostic category.

Principal and Provisional Diagnoses

Principal diagnosis: The diagnosis of the client’s “presenting problem”

Provisional diagnosis: A temporary diagnosis that is given because

the full criteria are not fully met

or the duration of symptoms necessary for a diagnosis hasn’t been met yet.

A provisional diagnosis has to be revised as new informationemerges or sufficient time has passed.