Chapters 1-2 DSM-IV-TR in Action

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Chapters 1-2DSM-IV-TR in Action

• Advanced Studies in Mental Disorders
• EPSY 6395
• Dr. Sparrow

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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

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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 clients 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.

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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 persons life situation.

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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.

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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.

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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/1
  62/10/1919

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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.

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Continuing Concerns

• Clients self-diagnosing -- sophomore syndrome
• Clients will begin acting the part.
• Others begin to expect and condone behavior
  because its 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.

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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

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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!

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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.

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Chapter TwoBasics and Applications

• The DSM is an essential starting point in
  determining the nature of a clients problem.
• It does not provide treatment approaches, so
  companion books are necessary.
• It should only be used by professionals.

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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?

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Multidisciplinary vs. interdisciplinary approaches

• An interdisciplinary approach is a team approach
  to a comprehensive assessment and treatment plan.
  Its more likely to happen within an institution
  that employs a variety of health professionals.
• Where in your current career is there a
  multidisciplinary approach?

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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

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Diagnosis and Assessment

• Diagnosis should always relate directly to the
  clients 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.

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Diagnosis and Assessment

• Diagnostic product is the sum total of the
  information collected during the assessment.
• 1 Corey
• Whats happening?
• What does the client want?
• What is the client learning in therapy?
• To what extent is the client applying what is
  learned?

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Diagnosis and Assessment

• 2 Carlton (biomedical, psychological and social)
• Biomedical -- first priority
• any physical disability and its impact
• client s view of health status

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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?

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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

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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.

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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

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Clinically Significant

• Very important Even if a client meets the
  threshold criteria for a DSM-IV disorder, he or
  she should not receive a diagnosis unless the
  clients individual, social, and occupational
  functioning is impaired.

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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 -- ones roots, ancestry, and
  heritage--while ethnic identity is the acceptance
  of ones ethnicity
• Race is defined as a consciousness of status or
  identity based on ancestry and color

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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.

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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?

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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

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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?

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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.

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Principal and Provisional Diagnoses

• Principal diagnosis The diagnosis of the
  clients 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 hasnt been met yet.

A provisional diagnosis has to be revised as new
information emerges or sufficient time has passed.
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ARTICLE BY DR. SPARROW ON THE MULTICULTURAL
ASPECTS OF THE DSM
Continued
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