Diagnostic and Statistical Manual

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Diagnostic and Statistical Manual

• Encyclopedia of current
• psychiatric diagnoses in the U.S.
• Published by the American
• Psychiatric Association
• The latest version is the DSM-IV-
• TR (4th edition, text revision)

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DSM-IV-TR

• Ratings are made on 5 different dimensions,
  called axes
• The 5 axes describe several different features
  that contribute to an individuals presentation
  and broadens the clinicians understanding of the
  individual
• This multiaxial classification system was first
  implemented in the DSM-III, and continued in
  subsequent editions (DSM-IV and DSM-IV-TR)

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DSM-IV-TR (cont.)

• Axis I all psychiatric diagnostic categories,
  except personality disorders and mental
  retardation
• E.g., posttraumatic stress disorder, anorexia
  nervosa, schizophrenia
• Axis II personality disorders and mental
  retardation
• E.g., schizoid personality disorder, antisocial
  personality disorder
• Axis III medical conditions that are relevant
  to the psychiatric disorder
• E.g., cancer, AIDS, diabetes mellitus
• Axis IV psychosocial and environmental problems
  
• E.g., homelessness, joblessness
• Axis V global assessment function (GAF) is a
  number from 1-100 that is assigned to an
  individual, which determines their level of
  functioning and alludes to their need for
  treatment, level of treatment, as well as
  prognosis
• The higher the number, the higher functioning the
  person

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Axis I Disorders

• Disorders Usually First Diagnosed in Infancy,
  Childhood or Adolescence
• Intellectual, emotional, social and physical
  disorders that begin at or before adolescence
• E.g., separation anxiety disorder, attention
  deficit/hyperactivity disorder, learning
  disorders
• Delirium, Dementia, Amnestic and Other Cognitive
  Disorders
• Cognition is seriously disturbed
• Delirium clouded consciousness, wandering
  attention, incoherent thinking
• Dementia deterioration of mental capacities,
  especially memory
• E.g., Dementia of the Alzheimers Type
• Amnesia memory impairment without delirium or
  dementia

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Axis I Disorders (cont.)

• Substance-Related Disorders
• dependence, abuse, intoxication, withdrawal
• Alcohol, amphetamine, caffeine, cannabis, etc.
• Schizophrenia and Other Psychotic Disorders
• loss of contact with reality, deterioration in
  functioning, language and communication
  disturbance, delusions and hallucinations
• E.g., schizophrenia, schizoaffective disorder,
  delusional disorder

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Axis I Disorders (cont.)

• Mood Disorders
• Feelings of extreme and inappropriate sadness or
  euphoria for extended periods of time.
• E.g., major depressive disorder, bipolar disorder
• Anxiety Disorder
• Characterized by irrational or excessive fear
• E.g., phobias, panic disorder, agoraphobia,
  obsessive-compulsive disorder, posttraumatic
  stress disorder

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Axis I Disorders (cont.)

• Somatoform Disorders
• Characterized by the presence of physical
  symptoms with no known physiological cause, but
  which seem to serve a psychological purpose
• E.g., pain disorder, conversion disorder,
  hypochondriasis, body dysmorphic disorder
• Factitious Disorders
• Complaints of physical or psychological symptoms
  where it is assumed that the individual has some
  psychological need to assume a sick role
• Also known as Munchausens syndrome

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Axis I Disorders (cont.)

• Dissociative Disorders
• Memory and identity are disrupted by a sudden
  alteration in consciousness.
• E.g., dissociative amnesia, dissociative fugue,
  dissociative identity disorder, depersonalization
  disorder
• Sexual and Gender Identity Disorders
• Three subcategories
• Paraphilias unconventional sexual gratification
• E.g., frotteurism, exhibitionism, voyeurism
• Sexual Dysfunction problems with sexual
  response
• E.g., hypoactive sexual desire disorder,
  premature ejaculation
• Gender Identity Disorders discomfort with
  sexual anatomy and identification as the opposite
  sex
• Also known as transsexualism

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Axis I Disorders (cont.)

• Eating Disorders
• Abnormal eating patterns that significantly
  impair functioning
• E.g., anorexia nervosa, bulimia nervosa
• Sleep Disorders
• Disturbances in the amount, quality or timing of
  sleep the occurrence of unusual events during
  sleep
• E.g., primary insomnia, primary hypersomnia,
  narcolepsy, breathing-related sleep disorder,
  nightmare disorder

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Axis I Disorders (cont.)

• Impulse Control Disorders Not Elsewhere
  Classified
• Behavior is inappropriate and seemingly out of
  control
• E.g., intermittent explosive disorder,
  kleptomania, pyromania, pathological gambling,
  trichotillomania
• Adjustment Disorders
• The development of emotional or behavioral
  symptoms following a major life stressor. These
  symptoms do not meet criteria for another Axis I
  disorder

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Axis II Disorders

• Personality Disorders
• Enduring, inflexible and maladaptive patterns of
  behavior and inner experience
• E.g., paranoid personality disorder, narcissistic
  personality disorder, avoidant personality
  disorder
• Mental Retardation
• Significantly sub-average intelligence
• Onset before age 18
• Deficits or impairment in other areas of
  functioning
• Found in DSM-IV-TR under Disorders Usually First
  Diagnosed in Infancy, Childhood or Adolescence
• But diagnosed on Axis II

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More on Personality Disorders

• Why are personality disorders placed on a
  separate axis?
• They tend to be egosyntonic
• Represent baseline functioning
• Tend to be chronic and stable

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Issues in the Classification of Mental Illness

• Some criticism of the (current) diagnostic system
• Doesnt encompass the totality of a person
• Stigmatizing and degrading
• Our categorical classification system does not
  consider the continuity of behavior from normal
  to abnormal
• Subjective factors still play a role in making
  diagnoses (what is included in the DSM and what a
  clinician labels a person)
• Day-to-day interrater reliability is probably
  lower than field trials

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Issues in the Classification of Mental Illness

• Value of the (current) diagnostic system
• Common language of mental health professionals
  that conveys information about an individual
• Allows professionals to search for causes and
  treatments of particular disorders
• Facilitates research and adds to our body of
  knowledge of psychopathology
• Interrater reliability has improved since the
  DSM-III for most diagnostic categories

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Clinical Assessment

• More or less formal approach to understanding a
  person
• Results are used to diagnose and treat an
  individual
• As clinicians and laypersons, we are always
  assessing ourselves and others
• Psychologists use a variety of techniques to
  assess cognitive, emotional, personality, and
  behavioral variables

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Clinical Assessment (cont.)

• The utility of an assessment instrument is
  determined by its reliability and validity
• Reliability how consistent is this measure?
• Some types of reliability include interrater
  reliability, test-retest reliability, etc.
• Validity does this instrument measure what it
  purports to measure?
• Some types of validity include construct
  validity, predictive criterion validity, etc.

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Psychological Assessment

• Clinical Interviews
• Amount of structure varies by purpose, setting,
  style of the interviewer
• E.g., Structured Clinical Interview for Axis I of
  DSM-IV (SCID)
• Reliability and validity are good
• The more structure, the more confident an
  interviewer can be about making diagnostic
  judgments and comparisons with others who were
  given the same structured interview
• Clinician pays attention to the process as well
  as content of responses

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Psychological Tests

• Standardized procedures to measure performance on
  a given task
• Statistical norms are established by analyzing
  the responses of many people
• Intelligence Tests
• E.g., Wechsler Adult Intelligence Scale (WAIS)
• Measures cognitive abilities
• Objective Personality Inventories
• E.g., Minnesota Multiphasic Personality
  Inventory-2 (MMPI-2)
• Self-report inventory that measures both
  personality and psychopathology

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Projective Personality Tests

• Based on hypothesis that a person projects
  their thoughts and feelings on to an ambiguous
  stimuli
• Rorschach Inkblot Test
• Subject describes what the inkblot might be, and
  then provides an explanation for why s/he gave
  those responses
• Thematic Apperception Test (TAT)
• Subjects tells a story about the picture

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Behavioral Assessment

• Behavioral observation focuses on the situational
  determinants of behavior
• Stimuli that precedes the problem
• Organismic factors (psychological and
  physiological) that affect behavior
• Responses (the main focus of behavioral
  therapists)
• Consequences that seem to reinforce or punish the
  response
• Assessment is linked to intervention, with
  sequence of events analyzed in terms of learning
  framework
• Self monitoring
• E.g., Ecological Momentary Assessment (EMA)
• Subject assesses their own behavior
• Problem with reactivity behavior may be altered
  due to self-monitoring

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Cognitive Assessment

• Methods tend to be theoretical and data driven
• Get at thoughts that underlie behavior and moods
• Can be questionnaires, interviews, self-reports
• E.g., Beck Depression Inventory (BDI)
• Recollection of thoughts during assessment
  procedure may not reflect thoughts during event
• Articulated Thoughts in Simulated Situations
  (ATSS) avoids this problem
• Subject reports thoughts on hypothetical
  situations

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Biological Assessment

• Brain imaging
• Computerized Axial Tomography (CAT or CT scan),
  Magnetic Response Imaging (MRI), Functional
  Magnetic Response Imaging (fMRI), Positron
  Emission Tomography (PET scan)
• Neurochemical Assessment
• Postmortem studies look at the amounts of a
  neurotransmitter found in specific brain regions
• Indirect assessment via analysis of metabolites
  of neurotransmitters in bodily fluids
• Neuropsychological Assessment
• Neuropsychological tests assess behavioral
  disturbances thought to arise from brain
  dysfunctions
• E.g., Halstead-Reitan and Luria Nebraska
  batteries
• Psychophysiological Measurement
• E.g., electrocardiogram (EKG), electroencephalogra
  m (EEG)

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Cultural Issues in Psychological Assessment

• Assessment paradigms tend to be based on the
  cultures of white, European-Americans
• Some psychological measures can be culturally
  biased
• Cultural bias in psychological testing can lead
  to underpathologizing or overpathologizing,
  as well as the type of diagnosis given
• Differences between therapist and client in terms
  of language, expression of symptoms, style of
  test-taking, can effect the outcome of an
  assessment

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Avoiding or Minimizing Cultural Bias in Assessment

• Assessor should learn about the cultures of the
  population they work with
• Testing can be conducted in the clients
  preferred language
• Make certain that the subject understands the
  assessment procedures and instructions
• Always make sure that rapport is established
  before proceeding with testing