Introduction to DSM-IV TR

Dr. Phang Cheng Kar

Lecturer & Psychiatrist, UPM
Diagnostic & Statistical Manual
of Mental Disorders,
4th Edition, Text Revision
 History of the DSM
• DSM-I 1952
• DSM-II 1968
• DSM-III 1980
• DSM-III-R 1988

• DSM-IV 1993
• DSM-IV-TR 2000 (Over 200 disorders)
What is considered
abnormal/illness/disorder?

…The most widely accepted definition

used in DSM-IV-TR describes
behavioral, emotional or cognitive
dysfunctions that are unexpected in their
cultural context and associated with
personal distress or substantial
impairment in functioning.
What can you find in DSM-IV?
 Names of various mental disorders
 Symptoms & features of various mental
disorders
 Diagnostic criteria of mental disorders
 Differential diagnosis
 X causes
 X treatment
Common DSM-IV Disorders…
 Mood Disorders
 Anxiety Disorder
 Disorders usually first diagnosed in
Childhood & Adolescence
 Dementia, Delirium & other cognitive
disorders
 Schizophrenia & psychotic disorders
 Substance-related disorders
 Mental Disorders due to general medical
conditions
Less common DSM-IV disorders…
 Eating Disorders
 Sexual Disorders
 Sleep Disorders
 Personality Disorders
 Somatoform Disorders etc.
Major Depressive Disorder
• Depressed mood
• Loss of interest, pleasure or
motivation
• LOW/LOA
• Insomnia or hypersomnia
• Poor concentration or memory or
indecisiveness
• Easily tired or fatigue
• Psychomotor agitation or retardation
• Feeling useless, worthless or guilty
• Hopelessness, suicidal thought or
attempt
Major Depressive Disorder

• 5/9
• 1/2
• 2 weeks
• Everyday, throughout the day
• Not due to drugs
• Not due to medical conditions
• Not part of bereavement
• Not part of bipolar disorder
• Not part of psychotic disorder
• Significant impairment in
function
How should counselors
recognize the symptoms?
• Sad & crying – Depressive Disorders
• Abnormal Happy – Bipolar Disorders
• Fear & Worry – Anxiety Disorders
• Weird/Odd – Schizophrenia

• Psychological rating scales e.g. DASS,

BDI, BAI etc.
When should counselors refer
patients to see a psychiatrist?
 Psychotic disorders
 Bipolar disorders
 Suicidal
 Violent
 Suspected medical causes e.g. thyroid
 Multiple medical problems e.g. elderly
 Alcohol/heroin/substance dependence
 Significant impairment in functions e.g. not
eating, not sleeping, can’t work
 Multiple problems & not improving
 MC & medical report
Psychosis/Schizophrenia
 TREATMENT…

Biological
(生物 •Antidepressant
•Antipsychotic
shēng​wù) •Mood stabilizer
What would a psychiatrist do?
 A detail interview about your symptoms &
background
 Collateral history from friends/family
 Mental state examination
 Physical examination
 Blood, urine, imaging investigations
 Psychological tests
 Diagnosis & psycho-education
 Individualized treatment plan – medications
or/and counseling/psychotherapy & ward
admission if severe
Diagnosis in DSM-IV…
 Multi-axial Dx:

 Axis I: Clinical Disorders

 Axis II: Personality Disorders/Mental Retardation
 Axis III: General Medical Condition
 Axis IV: Psychosocial & Environmental Problems
 Axis V: Global Assessment Functioning

Provides a format for organizing and communicating

complex clinical information.
Mental Health Diagnosis…
 Example I:

 Axis I: Major Depression

 Axis II: Anxious & obsessive personality
 Axis III: Breast cancer
 Axis IV: Financial problem
 Axis V: Function - can’t manage household
- interfere with cancer treatment
Mental Health Diagnosis…
 Example II:

 Axis I: Mood Disorder due to Medical Condition

 Axis II: None
 Axis III: Hypothyroidism
 Axis IV: Poor family support – accuse of malingering
 Axis V: Function – can’t drive & get out of house
Mental Health Diagnosis…
 Example III:

 Axis I: Major Depressive Disorder

 Axis II: Low self-esteem
 Axis III: Diabetes Mellitus
 Axis IV: Poor social support
 Axis V: Function – neglected self-care
 CAUSES & TREAMENT
• Genetics
Biological • Hormonal
• Brain injury
(生物 shēng​wù) •
•
Drug abuse
Physical illness

• Personality -
Psychological anxious/pessimistic/perfectionist
• Family/marital problem

(心理 xīn​lǐ​) • History of child abuse

• Keep things to himself/herself
• Pathological grief

• Unemployment
Social • Financial difficulty
• Stressful work environment
(社会 shè​huì) • Political instability
• Natural disaster
What can a counselor do to support a
psychiatrist in managing patients/ clients?
 Make a good referral to psychiatrists
 Advice on referral system
 Therapeutic listening
 Manage various Axis-IV problems
 Skills training – relaxation, problem solving,
communication
 Specific therapy e.g. CBT, family therapy
 Don’t simply say that medicine is no good !!!
 Encourage to seek 2nd opinion if patient doesn’t
click well with psychiatrist
 What if my so and so refuse
to see a psychiatrist?
• See a counselor or clinical psychologist
• See a GP for physical symptoms of depression
• See a private psychiatrist – more convenient time
• Get a second opinion from another psychiatrist
• Introduce websites/brochures/talks on depression
• Many great people suffered from depression too..
• Online therapy e.g. MoodGym
• Seek advice from a psychological minded Sangha member
• Get help from someone whom patient respects & listens to
• You see a psychiatrist & ask him/her to accompany you
• Make a police report if violent to self or others
Importance of DSM-IV
 Reduce mis-diagnosis
 Professional standard
 Speaking common language
 Psycho-education
 Facilitate referral
 Research purpose
Limitations of DSM-IV
 Not self-rating
 No causes
 No treatment
 Interviewing skills required
 Mental state examination skills
required
 Pathologizing a normal experience?
 Stigma? Over-medications…