DSM-IV-TR in Action

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 clients 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 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
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/162/10/1
919

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 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
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 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 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. 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
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 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 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
Whats 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,
cognitive-behavioral, 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

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

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 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.