Chapters 1-2
DSM-IV-TR in Action
Advanced Studies in Mental Disorders
EPSY 6395
Dr. Sparrow
Chapter One
Getting Started
The Bibles of Mental Health Assessment
The DSM -- Diagnostic and Statistical Manual of Mental
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 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 nonmedication 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 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
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
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
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
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 Two
Basics 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
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, cognitivebehavioral, 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
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 client’s 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
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
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.
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
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
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
Provisional diagnosis: A temporary diagnosis that is given
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 information
emerges or sufficient time has passed.
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Chapters 1-2 DSM-IV-TR in Action