Transcript Chapter_11

Chapter 11
Diagnosis and Writing the
Assessment Process
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The Importance of Diagnosis
Read vignettes at beginning of chapter (pp.
245-246)
Some reasons for its current importance:
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Changes in federal laws (e.g., IDEIA)
Needed for 3rd party payments
To communicate with other clinicians
Many diagnoses are likely biologically caused—
thus definitive diagnosis is needed for proper
treatment
Helpful for case conceptualization and treatment
planning
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What is DSM-IV-TR?
Diagnosis: Derived from the Greek words dia
(apart) and gnosis (to perceive or to know)
DSM-I developed in 1952 by Am. Psychiatric
Association
Today, five axes:
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Axis I: Clinical Disorders and Other Conditions That
May Be a Focus of Clinical Attention
Axis II: Personality Disorders and Mental
Retardation
Axis III: General Medical Conditions
Axis IV: Psychosocial and Environmental Problems
Axis V: Global Assessment of Functioning.
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Axes I and II:
The Mental Disorders
Each mental disorder covered in DSM-IV-TR
describes:
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the disorder’s main features
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subtypes and variations in client presentations
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the typical pattern, course, or progression of
symptoms
how to differentiate the disorder from other, similar
ones
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Cultural Issues
and the Mental Disorders
Some things not diagnosable:
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Client reactions to expected culturally appropriate
reactions to life events (e.g., loss of loved one and
depression)
Phase of life developmental issues
Culturally specific reactions that may seem
unusual in “western” culture
Most problems not “diagnosable” and for
those who have a “diagnosis,” most live
relatively “normal” lives
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Cultural Issues and
the Mental Disorders (Cont’d)
Throughout DSM-IV-TR acknowledgement is
made of gender, cultural, and age differences
DSM includes appendix of culture-specific client
experiences not included elsewhere (E.g.,
Koro):
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A term, probably of Malaysian origin, that refers to
an episode of sudden and intense anxiety that the
penis (or in females, the vulva and nipples) will
recede into the body and possibly cause death. . . .
(APA, 2000, p. 900)
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Axis I Disorders
Clinical Disorders and Other Conditions That
May Be a Focus of Clinical Attention
All disorders except for those classified as
personality disorders or as mental retardation
(Axis II disorders)
Considered treatable in some fashion and
are often reimbursable
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The Axis I Disorders
Delirium, Dementia,
Amnestic, and Other
Cognitive Disorders
Mental Disorders Due to a
General Medical Condition
Substance-Related
Disorders
Schizophrenia and Other
Psychotic Disorders:
Mood Disorders
Anxiety Disorders
Somatoform Disorders
Factitious Disorders
Dissociative Disorders
Sexual and Gender
Identity Disorders
Eating Disorders
Sleep Disorders
Impulse Control Disorders
Not Elsewhere Classified
Adjustment Disorders
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Axis II Disorders: Personality
Disorders and Mental Retardation
Long-term disorders in which treatment
almost always has little or no affect on
changing presenting symptoms of the
individual.
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The Axis II Disorders
Mental Retardation: Intellectual functioning
below 2nd percentile and problems with
adaptive skills
Four categories:
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mild (IQ of 50-55 to 70)
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moderate (IQ of 35-40 to 50-55)
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severe (IQ of 20-25 to 35-40)
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profound (IQ below 20 or 25)
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The Axis II Disorders (Cont’d)
Personality Disorders: Deeply ingrained,
inflexible, and enduring patterns of relating
that lead to distress and impairment.
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Cluster A: paranoid, schizoid, and schizotypal
disorders. Characteristics: odd or eccentric.
Cluster B: antisocial, borderline, histrionic, and
narcissistic disorders. Characteristics: dramatic,
emotional, overly sensitive, and erratic.
Cluster C: avoidant, dependent, and obsessivecompulsive disorders. Characteristics: anxious and
fearful traits.
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The Axis I and Axis II Disorders
Role Play Activities:
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Axis I: Exercise 11.1, p. 251
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Axis II: Exercise 11.2, p. 252
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Axis III: General Medical Conditions
Medical conditions
Either reported on Axis III alone, or reported
on Axis III and Axes I or II also if it causes
the disorder.
Use ICD-9-CM code (abbreviated table in
DSM-IV-TR
Exercise 11.3, p. 253
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Axis IV: Psychosocial and
Environmental Problems
Psychosocial or environmental problems that
affect the diagnosis, treatment, and prognosis
Either reported on Axis IV alone, or reported
on Axis IV and Axes I or II also if it causes
the disorder
Exercise 11.4, p. 253
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Axis V: Global Assessment
of Functioning (GAF)
Used to assess the overall functioning of the
client. Based on client’s psychological, social,
and occupational.
Can indicate current functioning, functioning
of past 6 months, and so forth.
Important for showing that progress is being
made.
See Table 11.1, p. 254
Exercise 11.5, p. 255
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Making a Diagnosis
DSM offers a decision tree to help in making
a diagnosis
Client can have more than one diagnosis
Example:
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Axis I: 309.0, Adjustment Disorder with Depressed Mood
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Axis II: 301.82, Avoidant Personality Disorder
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Axis III: V71.09 No Diagnosis
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Axis IV: Divorce
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Axis V: GAF = 60 (current), 75 (highest in past year)
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Final Thoughts on DSM-IV-TR
Part of total assessment process
With clinical interview, use of tests and
informal assessment procedures, provides
broad understanding of client helps in
treatment planning
The more “pieces of information,” the better
your predictions about the client.
Exercise, 11.6: Using the Five Axes (p. 256)
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