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 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 nonmedication 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 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 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, 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 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 information emerges or sufficient time has passed. ARTICLE BY DR. SPARROW ON THE MULTICULTURAL ASPECTS OF THE DSM Continued Go to next slide and then return to this page for righthand column Go back to top of right column on previous page. Go to next slide and then return to this page for right-hand column Go back to top of right column on previous page.