DIAGNOSIS
Why diagnose?

To define clinical entities
Typical symptom cluster
 Natural history
 Causes


To determine treatment
Arguments Against
Diagnosis is imposed from outside
by an expert, not by the client.
 Diagnostic categories minimize the
uniqueness of each client.
 Focus on signs and symptoms
ignores capacity for self-healing.

More Arguments Against
Diagnosis is inconsistent with a
strengths approach.
 Diagnosis can lead to self-fulfilling
prophecy and despair.
 Diagnosis leads professionals to
ignore significant data that do not
support the diagnosis.

More Arguments Against
Diagnosis leads to identification of
pathology as being within individuals
instead of within systems.
 The diagnostic system tends to
ignore culture, age, gender, etc.
 Many people who use the DSM are
not qualified to use it.

Rebuttals to Arguments
If the phenomena exist, for
professionals to ignore them
regardless of client perception would
be irresponsible.
 Diagnostic categories don’t minimize
client uniqueness, although people
might.

More Rebuttals
Diagnosis does not minimize selfhealing, and may facilitate it, if it is
associated with good data.
 The strengths perspective does not
ask us to ignore the identification
and definition of problems.

More Rebuttals
Diagnosis can lead to change and
hope.
 Skilled practice does not ignore
data. Diagnosis helps organize
data.
 If some pathology does exist within
individuals, to ignore the fact would
not help change the system.

More Rebuttals

If diagnostic labels accurately
describe real sets of phenomena,
the prevalence rates among groups
is a matter for research, not for
throwing out the labels just because
they fit more members of some
groups than others.
More Rebuttals

If people don’t know how to use a
tool, training on the use of the tool
and limiting access to those who
know how to use the tool make
more sense than throwing out the
tool.
Arguments for Diagnosis
Diagnosis is required for
reimbursement.
 Clear definition of problems is
necessary for focused treatment .
Diagnosis is a tool for definition.
 To work in the field, workers must
use diagnostic procedures.

More Arguments For
Standard diagnostic nomenclature is
essential for communication with
other professionals.
 Diagnosis sets a path toward
appropriate treatment.
 The diagnostic process helps
differentiate problems.

More Arguments For
Diagnosis helps workers screen for
problems and manage client safety.
 Accurate diagnosis is necessary for
the research foundation of evidencebased practice.

Rebuttals to Arguments For
“Required for reimbursement” is not
a compelling moral argument.
 “Required to work in the field” is not
a compelling moral argument.
 Others?

Signs, Symptoms, and
Issues
Signs – observable phenomena
 Symptoms – subjective experiences
 Issues – ideas about signs,
symptoms, and circumstances

Diagnostic approaches
Descriptive – the “what”
 Psychological or inferential – the
“why”
 Dimensional – focuses on elements,
not categories

Diagnostic approaches continued

Categorical – implies that the
categories are discovered
Observation leads to recognition of
clusters
 Diagnoses are labels of clusters

Limitations of a categorical
approach
Categories are not necessarily
homogeneous.
 Boundaries between classes are not
always clear.
 Classes are not mutually exclusive.

Two diagnostic principles
Parsimony
 Hierarchy

Seven steps for diagnosis
Collect data
 Identify pathology
 Evaluate data reliability
 Determine the distinctive feature
 Arrive at a diagnosis
 Check diagnostic criteria
 Resolve diagnostic uncertainty

What is a mental disorder?
It is what we define it to be.
 A clinically significant
 behavioral or psychological
syndrome or pattern
 that occurs in an individual,
 is associated with present distress or
disability

Mental disorder - continued
or significantly increased risk of
death, pain, disability
 or important loss of freedom.
 The behavior or pattern must not be
 an expectable or culturally
sanctioned
 response to an event.

The DSM is meant to be
used by people;
with appropriate training and
experience,
 who know how to use clinical
judgment,
 who have directly assessed the
individual.
 See the “cautionary statement.”

Ethnic and Cultural
Considerations
Culture may influence expression of
illness. Individuals have a right to
define their culture.
 Pathology must be diagnosed within
a cultural context.

Ethical Considerations
Why would a social worker use
psychiatric diagnoses?
 Who may diagnose mental illness?
 What are the implications of
labeling?
 Who should know what labels are
being used?
 What do the labels mean to the
individuals?

The Multiaxial System
Axis I – Clinical Disorders and Other
Conditions
 Axis II – Personality Disorders
 Axis III – General Medical Conditions
 Axis IV – Psychosocial and
Environmental Problems
 Axis V – Global Assessment of
Functioning

Major Diagnostic
Categories

Disorders usually first diagnosed in
infancy, childhood, or adolescence
Mental Retardation
 Learning Disorders
 Motor Skills Disorder

Childhood disorders continued
Communication Disorders
 Pervasive Developmental Disorders
 Attention Deficit and Disruptive
Behavior Disorders

Childhood disorders continued
Feeding and Eating Disorders of Infancy
and Early Childhood
 Tic Disorders
 Elimination Disorders
 Other Disorders of Infancy, Childhood,
and Adolescence

Diagnoses - continued
Delirium, Dementia, Amnestic, and
Other Cognitive Disorders
 Mental Disorders Due to a General
Medical Condition Not Elsewhere
Classified
 Substance Related Disorders
 Schizophrenia and Other Psychotic
Disorders

Diagnoses - continued
Mood Disorders
 Anxiety Disorders
 Somatoform Disorders
 Factitious Disorders
 Dissociative Disorders
 Sexual and Gender Identity
Disorders
 Eating Disorders

Diagnoses - continued
Sleep Disorders
 Impulse-Control Disorders Not
Otherwise Classified
 Adjustment Disorders
 Personality Disorders

Diagnoses - continued

Other Conditions That May Be a
Focus of Clinical Attention
Psychological Factors Affecting
Medical Condition
 Medication-Induced Movement
Disorders
 Other Medication-Induced Disorder
 Relational Problems

Other - continued
Problems Related to Abuse or Neglect
 Additional Conditions That May Be a
Focus of Clinical Attention

Additional Codes
Unspecified Mental Disorder
 No Diagnosis
 Diagnosis Deferred

Lingering Questions
Is conservative diagnosis more
ethical than liberal diagnosis?
 Must someone have an illness to
need treatment?
 Must someone have an illness to
benefit from treatment?
 Do we treat illness or people?

Childhood
Depression as an
Example
Is there such a thing as
depression in children?
Some say yes.
 Some say no.

Views of depression in
children.
It is a developmental condition that
disappears with time.
 It is similar to adult depression, with
some additional features.
 It is not expressed in overt
depressive symptoms but is masked
by other symptoms.

Views continued
Young children cannot be depressed
because they lack the cognitive
development necessary for the
psychological mechanisms involved
to occur.
 It is a result of the loss of the love
object and may occur in infants.

Views continued
There is a biological basis.
 It is triggered by events.
 It is consequent to the difficulties
imposed by other illnesses such as
attention deficit problems and other
learning problems.

Views continued
It is the consequence of faulty
cognitions.
 It is a behavioral response to
punishment or lack of
reinforcement.
 It is a response to anxiety.
 It is learned helplessness.

Views continued

There are many psychoanalytic
views hinging on putative
psychological mechanisms.
Problems
Depression is not a thing.
 Depression as an illness and
depression as a mood are confusing
concepts.
 If we define depression as a set of
symptoms, we enter into circular
logic.

Problems continued

If we define depression as a certain
biochemical condition, we ignore the
behavioral manifestations. There
may be people with the biochemical
condition who don't have symptoms,
and there may be people with
symptoms without the biochemical
condition.
Problems continued
We have similar problems if we
define it by its response to
antidepressants.
 Any definition that involves
psychological mechanisms is not
subject to disproof and consequently
is not scientific.

Problems continued

"It would be unethical to assume
that a child manifesting no clear
signs of depression is nevertheless
depressed, particularly if this
resulted in the administration of
antidepressant drugs. It would be
unwise and unscientific, however,
to assume that depression, as a
primary problem, does not occur in
children."
Common signs and
symptoms of depression
persistent depressive mood for two
weeks or more
 inability to derive pleasure from
normal activities
 loss of interest in normal activities
 psychomotor retardation or agitation

Signs and symptoms
continued
sleep disturbance
 loss or increase of appetite
 sense of hopelessness
 sense of worthlessness

Signs and symptoms
continued
impaired memory and concentration
 suicidal thoughts
 irritability
 anxiety

Signs and symptoms
continued

A convenient way of thinking of
depression is that it looks like a
normal grief reaction, but it lasts
longer.
Types of depression:
major depression, with several
subtypes;
 dysthymia;
 depression as part of bipolar
disorder;
 depression as part of cyclothymia;
 adjustment disorders, normal
bereavement, and other normal
reactions to circumstances.

Conditions that mitigate
against a diagnosis
Bizarre behavior, delusions, or
hallucinations in the absence of
the depression
 A known organic cause for the
depression
 Depression following the loss of a
loved one
 A depression of less than two
weeks duration

Important considerations

Depression should be formally
diagnosed only by someone with
sufficient training and experience to
adequately consider all of the
relevant factors and to rule out
other illnesses that may present as
depression. This will usually mean a
medical doctor with specialized
training in child psychiatry.
Considerations continued
Depression involves all body
systems.
 Depression may have behavioral
manifestations.
 Depression interferes with normal
thinking patterns.

Cognitive Distortions of
Depression
difficulty concentrating and
remembering
 exaggerations or misinterpretations
of events
 extreme or absolute judgements
 over generalization

Distortions continued
focus on details to the exclusion of
other data
 draw inferences in the absence of
supporting evidence
 attribute personal significance to
unpleasant events

Treatment of Depression
serotonin reuptake inhibitors
(Celexa, Paxil, Prozac, Zoloft)
 tricyclics and heterocyclics
(Anafranil, Desyrel, Pamelor, Elavil)
 monoamine oxidase inhibitors
(Marplan, Nardil, Parnate)

Treatment - continued
Cognitive Behavioral Therapy
 Interpersonal Therapy
