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Chapters 1-2 DSM-IV-TR in Action


DSM-IV-TR in Action Advanced Studies in Mental Disorders EPSY 6395 Dr. Sparrow Go back to top of right column on previous page. Go to next and then return to ... – PowerPoint PPT presentation

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Title: Chapters 1-2 DSM-IV-TR in Action

Chapters 1-2DSM-IV-TR in Action
  • Advanced Studies in Mental Disorders
  • EPSY 6395
  • Dr. Sparrow

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
  • Tendency to underdiagnose as a form of protection
    of clients privacy, domestic defense, and job
  • 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
  • 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.

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
  • 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 --

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
  • 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 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

The Person in Environment Classification System
  • 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
  • Family therapy notion is that we live in nested
    systems person, family, community, nation, world

The Person in Environment Classification System
  • The PIE changed the way that Axis 4 on the DSM is
  • 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 clients 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
  • 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.
    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?

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
  • 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
    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
  • 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

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

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
  • 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)
  • 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
  • Gather an accurate definition of the problem.
  • Take beliefs and values into consideration
  • Assess culture and race issues
  • Assess competencies and resources

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.

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

  • 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
  • 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
  • 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

Subtypes and Course specifiers
  • The first three digits of the DSM code are the
  • 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
    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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