Transcript Class 8: Mental Illness and Diagnosis

Survey of Modern Psychology
Diagnosis and the DSM-IV-TR
The DSM-IV-TR
Diagnostic and Statistical Manual of Mental
Disorders
Fourth Edition
Text Revision
Mental Illness as Defined by the DSM
“each of the mental disorders is conceptualized as a clinically
significant behavioral or psychological syndrome or pattern that
occurs in an individual and that is associated with present distress
(e.g., a painful symptom) or disability (i.e., impairment in one or
more important areas of functioning) or with a significantly
increased risk of suffering death, pain, disability, or an important
loss of freedom. In addition, this syndrome or pattern must not be
merely an expectable and culturally sanctioned response to a
particular event, for example, the death of a loved one. Whatever
its original cause, it must currently be considered a manifestation of
a behavioral, psychological, or biological dysfunction in the
individual. Neither deviant behavior (e.g., political, religious, or
sexual) nor conflicts that are primarily between the individual and
society are mental disorders unless the deviance or conflict is a
symptom of a dysfunction in the individual, as described above”
The History of the DSM
• Classification of mental illness began in the US in
the 1840s
• It was used for collecting statistical information
• The first volume only contained the category of
“idiocy/insanity”
– In the 1880s, there were 7 categories of mental illness
1.
2.
3.
4.
5.
6.
7.
Mania
Melancholia
Monomania
Paresis
Dementia
Dipsomania
Epilepsy
The History of the DSM
• Other early classification of mental illness was
“Psychotic” vs. “Neurotic”
– Psychotic meant a loss of reality
– Neurotic meant any other mental health
symptoms that did not involve (consistent) loss of
reality
The History of the DSM
• In 1917, a new system was created
– It was primarily for statistical classification, but
began to have some clinical uses
• In the 1940s, the US army started to develop a
nomenclature to describe symptoms of WWII
servicemen and veterans
– The World Health Organization published the sixth
ICD (“International Classification of Diseases”) and
began including mental illness
The History of the DSM
• In 1952, the first DSM was published
– It contained a glossary of descriptions of
diagnostic categories
– Was the first official manual of mental disorders to
focus on clinical uses
• The second DSM contained more explicit
definitions, needed for reliable diagnosis, but
was not hugely different from the first DSM
The History of the DSM
• The DSM-III was published in 1980
• New additions were:
–
–
–
–
Explicit diagnostic criteria
Multiaxial system
Neutral theoretical approach
Based on empirical work/research
• One of the goals was a medical
nomenclature for clinicians and researchers
The DSM-III-R was published in 1987, due to
inconsistencies and unclear criteria lists
The History of the DSM
• Homosexuality originally appeared as a mental
illness in the DSM
– In the early 1970s, homosexuality in and of itself
was taken out of the DSM
– A new diagnosis of “sexual orientation
disturbance” was added, which referred to people
who believed that they were homosexual but were
upset by it and wanted to change
Perceptions of what constitutes a mental illness
can change over time based on changes in
research and public perception
The History of the DSM
• The DSM-IV was published in 1994
• It used a three stage empirical process:
1. Comprehensive and systematic reviews of the
published literature
2. Reanalysis of already collected data sets to
determine if criteria sets needed changes
3. Extensive field trials relating diagnosis to clinical
practice
• New diagnoses were added when necessary
– This was only done if research showed they
needed to be added; there is a section of “other
conditions that may be a focus of clinical attention”
The History of the DSM
• The DSM-IV-TR was published in 2000
• Incorporates new research, particularly
regarding course, prevalence, familial,
and demographic patterns
DSM Criteria
• Every diagnosis lists multiple criteria that must
be met for a diagnosis
– Some level of clinical judgment should be used,
particularly in cases where a client falls slightly
short of a single criterion
– There is a high level of agreement among
clinicians and researchers regarding the criteria
• A diagnosis is made based on the individual's
current state
DSM Criteria – Specifiers
Severity
• Severity describes the disorder when full criteria
are currently met
– Mild: few, if any, symptoms in excess of those required to
make the diagnosis are present, and symptoms result in no
more than minor impairment in social or occupational
functioning
– Moderate: symptoms or functional impairment between
“mild” and “severe” are present
– Severe: many symptoms in excess of those required to
make the diagnosis, or several symptoms that are
particularly severe, are present, or the symptoms result in
marked impairment in social or occupational functioning
DSM Criteria – Specifiers
Course
• This refers to a previous diagnosis
– In partial remission: The full criteria for the disorder were
previously met, but currently only some of the symptoms
or signs of the disorder remain
– Full remission: there are no longer any symptoms or signs
of the disorder, but it is still clinically relevant to note the
disorder – for example, in an individual with previous
episodes of Bipolar Disorder who has been symptom free
on lithium for the past 3 years. After a period of time in full
remission, the clinician may judge the individual to be
recovered and, therefore, would no longer code the
disorder as a current diagnosis.
DSM Criteria – Specifiers
Course
– The differentiation of In Full Remission from recovered
requires consideration of many factors, including the
characteristic course of the disorder, the length of time
since the last period of disturbance, the total duration of
the disturbance, and the need for continued evaluation or
prophylactic treatment
– Prior history: for some purposes, it may be useful to note a
history of the criteria having been met for a disorder even
when the individual is considered to be recovered from it.
Such past diagnosis of mental disorder would be indicated
in Prior History (e.g., Separation Anxiety Disorder, Prior
History, for an individual with a history of Separation
Anxiety Disorder who has no current disorder or who
currently meets criteria for Panic Disorder
DSM Criteria – Specifiers
• Provisional Diagnosis
– May be used if there is a strong presumption that
the full criteria will be met but there is not enough
information available (i.e., the individual cannot
give a full history)
– Diagnosis or differential diagnosis is dependent on
length of time
DSM Criteria – Specifiers
• Recurrence
– If symptoms occur after the individual has been in
remission, the diagnosis may be made without all
criteria being met (i.e., meeting criteria for a
Major Depressive Episode for 10 days instead of
the usually required 14)
DSM Criteria – Specifiers
Not Otherwise Specified
There are four instances when “not otherwise
specified” (NOS) would be used:
1. The presentation conforms to the general
guidelines for a mental disorder in the diagnostic
class, but the symptomatic picture does not meet
the criteria for any of the specific disorders. This
would occur either when the symptoms are
below the diagnostic threshold for one of the
specific disorders or when there is an atypical or
mixed presentation
DSM Criteria – Specifiers
Not Otherwise Specified
2. The presentation conforms to a symptom
pattern that has not been included in the
DSM-IV Classification but that causes clinically
significant distress or impairment. Research
criteria for some of these symptom patterns
have been in included in Appendix B
DSM Criteria – Specifiers
Not Otherwise Specified
3. There is uncertainty about etiology (i.e.,
whether the disorder is due to a general
medical condition, is substance induced, or is
primary)
DSM Criteria – Specifiers
Not Otherwise Specified
4. There is insufficient opportunity for complete
data collection (e.g., in emergency situations)
or inconsistent or contradictory information,
but there is enough information to place it
within a particular diagnostic class (e.g., the
clinician determines that the individual has
psychotic symptoms but does not have
enough information to diagnose a specific
Psychotic Disorder)
DSM Criteria – Specifiers
• Does not occur exclusively during the course
of…
– Some disorders may include the symptoms of
another
– The second disorder is not diagnosed if it occurs
only while the first diagnosis is present or in
partial remission
• i.e., a person may only show symptoms of bulimia
during periods of anorexia
DSM Criteria – Specifiers
• Substance Induced Disorders
– The symptoms/disorder are only present when a
substance has been used
• i.e., a person who hallucinates only after using marijuana
• General Medical Condition
– Some medical conditions can have symptoms
mirroring those of psychiatric disorders
– The psychiatric disorder is not diagnosed if the
symptoms disappear upon treatment of the medical
condition
Differential Diagnosis
• Some disorders can seem very similar to each
other or have overlapping symptoms
• Differential diagnosis decision trees help the
clinician rule out various other disorders
Multiaxial Assessment
There are 5 axes
I. Clinical Disorders
Other conditions that may be a focus of clinical attention
II. Personality Disorders
Mental Retardation
III. General Medical Conditions
IV. Psychosocial and Environmental Problems
V. Global Assessment of Functioning
Multiaxial Assessment
Axis I
• If an individual has more than one clinical
disorder, all should be reported on Axis I
– The main diagnosis or reason for seeking treatment
should be listed first
• If an Axis II diagnosis is the primary reason for seeking
treatment, it should be followed by “principal diagnosis”
• If there is no Axis I diagnosis, it should be coded
as V71.09
• If diagnosis is deferred pending additional
information, it should be coded as 799.9
Multiaxial Assessment
Axis I
• Disorders Usually First Diagnosed in•
Infancy, Childhood, or Adolescence •
(excluding Mental Retardation)
• Delirium, Dementia, and 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
Other Conditions that May Be a
Focus of Clinical Attention
Multiaxial Assessment
Axis II
• May also be used for noting prominent
maladaptive personality features or defense
mechanisms (that do not qualify as diagnoses)
Multiaxial Assessment
Axis II
•
•
•
•
•
•
•
Paranoid Personality Disorder
Schizoid Personality Disorder
Schizotypal Personality Disorder
Antisocial Personality Disorder
Borderline Personality Disorder
Histrionic Personality Disorder
Narcissistic Personality Disorder
•
•
•
Avoidant Personality Disorder
Dependent Personality Disorder
Obsessive-Compulsive Personality
Disorder
Personality Disorder Not Otherwise
•
•
Specified
Mental Retardation
Multiaxial Assessment
Axis III
• General medical conditions that are
potentially relevant to treating the mental
disorder
– The medical condition may cause the
psychological condition
– The psychological condition may be a reaction to a
medical condition
– The medical condition may impact the
pharmacological treatment of the psychological
condition
Multiaxial Assessment
Axis IV
• Psychosocial and environmental problems that may affect
the diagnosis, treatment, and prognosis of disorders on
Axis I or Axis II
• These include:
–
–
–
–
–
–
–
–
–
Problems with primary support group
Problems related to the social environment
Educational problems
Occupational problems
Housing problems
Economic problems
Problems with access to health care services
Problems related to interaction with the legal system/crime
Other psychosocial and environmental problems
Multiaxial Assessment
Axis V
• Evaluates the individual’s psychological, social, and
occupational functioning
– Does not include impairment due to physical or
environmental limitations
• The GAF is divided into 10 ranges of functioning and
requires that the clinician pick a single value
• Each range has two components in its description:
– Symptom severity
– Functioning
A lower GAF score is considered “worse”
Handout
Multiaxial Assessment
Axis V
• The GAF falls into a particular range if either
the symptom severity or level of functioning
falls into that range
– If the severity rating and function ratings are
discordant, the final rating reflects the worse of
the two scores
• i.e., an individual who is maintaining a social life and
holding a job (low impairment, so high GAF) but is
highly suicidal (high severity, low GAF) would have a
low final GAF score
Multiaxial Assessment
Axis V
1. Starting at the top level, evaluate each range
by asking, “is either the individual's symptom
severity or level of functioning worse than
what is indicated in the range description?”
2. Keep moving down the scale until the range
that best matches the individual’s symptom
severity or the level of functioning is reached,
whichever is worse.
Multiaxial Assessment
Axis V
3. Look at the next lower range as a double check against having
stopped prematurely. This range should be too severe on both
symptom severity and level of functioning. If it is, the appropriate
range has been reached (continue with step 4). If not, go back to
step 2 and continue moving down the scale
4. To determine the specific GAF rating within the selected 10-point
range, consider whether the individual is functioning at the higher
or lower end of the 10-point range. For example, consider an
individual who hears voices that do not influence his behavior
(e.g., someone with long standing Schizophrenia who accepts his
hallucinations as part of his illness.) If the voices occur relatively
infrequently (once a week or less), a rating of 39 or 40 might be
most appropriate. In contrast, if the individual hears voices almost
continuously, a rating of 31 or 32 would be more appropriate.
Cons of Diagnosis
• Forces labels on people and may be seen as
dehumanizing
• Stigma
Pros of Diagnosis
• Useful in research on mental illness and
treatment
• Often necessary on insurance forms
• May be less stigmatizing
– Conveys the idea that the person is not alone
– Diagnosis encourages mental illness to be
acknowledged as real
• Easier/more efficient discussion among
members of a treatment team
Mental Illness as Relative
• For symptoms to constitute a disorder, they
must result in impairment
• The behavior must also deviate from the
norm
– A criticism of the diagnosis of Attention
Deficit/Hyperactivity Disorder is that many
children are “hyper” and have difficulty sitting still
and concentrating in school
Attention Deficit/Hyperactivity
Disorder
A. Either (1) or (2):
(1)Six (or more) of the following symptoms of
inattention have persisted for at least 6
months to a degree that is maladaptive and
inconsistent with developmental level:
Attention Deficit/Hyperactivity Disorder
Inattention
a) often fails to give close attention to details or makes careless
mistakes in schoolwork, work, or other activities
b) often has difficulty sustaining attention in tasks or play activities
c) often does not seem to listen when spoken to directly
d) often does not follow through on instructions and fails to finish
schoolwork, chores, or duties in the workplace (not due to
oppositional behavior or failure to understand instructions)
e) often has difficulty organizing tasks and activities
f) often avoids, dislikes, or is reluctant to engage in tasks that
require sustained mental effort (such as schoolwork or
homework)
g) often loses things necessary for tasks or activities (e.g., toys,
school assignments, pencils, books, or tools)
h) is often easily distracted by extraneous stimuli
i) is often forgetful in daily activities
Attention Deficit/Hyperactivity
Disorder
(2) six (or more) of the following symptoms of
hyperactivity – impulsivity have persisted for
at least 6 months to a degree that is
maladaptive and inconsistent with
developmental level:
Attention Deficit/Hyperactivity Disorder
Hyperactivity
a)
often fidgets with hands or feet or squirms in seat
b)
often leaves seat in classroom or in other situations in which remaining seated is expected
c)
often runs about or climbs excessively in situations in which it is inappropriate (in adolescents or
adults, may be limited to subjective feelings of restlessness)
d)
often has difficulty playing or engaging in leisure activities quietly
e)
is often “on the go” or often acts as if “driven by a motor”
f)
often talks excessively
Impulsivity
g)
often blurts out answers before questions have been completed
h)
often has difficulty awaiting turn
i)
often interrupts or intrudes on others (e.g., butts into conversations or games)
Attention Deficit/Hyperactivity
Disorder
B. Some hyperactive-impulsive or inattentive symptoms that
caused impairment were present before age 7 years
C. Some impairment from the symptoms is present in two or
more settings (e.g., at school [or work] and at home)
D. There must be clear evidence of clinically significant
impairment in social, academic, or occupational
functioning
E. The symptoms do not occur exclusively during the course
of a Pervasive Developmental Disorder, Schizophrenia, or
other Psychotic Disorder and are not better accounted for
by another mental disorder (e.g., Mood Disorder, Anxiety
Disorder, Dissociative Disorder, or a Personality Disorder)
Conclusions
• The symptoms MUST CAUSE IMPAIRMENT OR
DISCOMFORT
• All other possibilities should be examined
BEFORE a mental illness is diagnosed
Possible New Additions: Binge Eating
Disorder
A. Recurrent episodes of binge eating. An
episode of binge eating is characterized
by both of the following:
1. eating, in a discrete period of time (e.g., within
any 2-hour period), an amount of food that is
definitely larger than most people would eat in a
similar period of time under similar circumstances
2. a sense of lack of control over eating during the
episode (e.g., a feeling that one cannot stop
eating or control what or how much one is eating)
Binge Eating Disorder
B. The binge-eating episodes are associated with three (or more) of the following:
1. eating much more rapidly than normal
2. eating until feeling uncomfortably full
3. eating large amounts of food when not feeling physically hungry
4. eating alone because of being embarrassed by how much one is eating
5. feeling disgusted with oneself, depressed, or very guilty after overeating
C. Marked distress regarding binge eating is present.
D. The binge eating occurs, on average, at least once a week for three months.
E. The binge eating is not associated with the recurrent use of inappropriate
compensatory behavior (i.e., purging) and does not occur exclusively during the
course of bulimia nervosa or anorexia nervosa.
Hoarding Disorder
A. Persistent difficulty discarding or parting with personal
possessions, even those of apparently useless or limited value,
due to strong urges to save items, distress, and/or indecision
associated with discarding.
B. The symptoms result in the accumulation of a large number of
possessions that fill up and clutter the active living areas of the
home, workplace, or other personal surroundings and prevent
normal use of the space. If all living areas are uncluttered, it is
only because of others’ efforts (e.g., family members,
authorities) to keep these areas free of possessions
C. The symptoms cause clinically significant distress or impairment
in social, occupational, or other important areas of functioning
(including maintaining a safe environment for self and others)
Hoarding Disorder
Specify if:
With Excessive Acquisition: If symptoms are accompanied by excessive
collecting or buying or stealing of items that are not needed or for which
there is no available space.
Specify whether hoarding beliefs and behaviors are currently characterized by:
Good or fair insight: Recognizes that hoarding-related beliefs and behaviors
(pertaining to difficulty discarding items, clutter, or excessive acquisition)
are problematic.
Poor insight: Mostly convinced that hoarding-related beliefs and behaviors
(pertaining to difficulty discarding items, clutter, or excessive acquisition)
are not problematic despite evidence to the contrary.
Delusional: Completely convinced that hoarding-related beliefs and
behaviors (pertaining to difficulty discarding items, clutter, or excessive
acquisition) are not problematic despite evidence to the contrary.
Non-Suicidal Self Injury
A. In the last year, the individual has, on 5 or more days,
engaged in intentional self-inflicted damage to the surface
of his or her body, of a sort likely to induce bleeding or
bruising or pain (e.g., cutting, burning, stabbing, hitting,
excessive rubbing), for purposes not socially sanctioned
(e.g., body piercing, tattooing, etc.), but performed with
the expectation that the injury will lead to only minor or
moderate physical harm. The absence of suicidal intent is
either reported by the patient or can be inferred by
frequent use of methods that the patient knows, by
experience, not to have lethal potential. (When uncertain,
code with NOS 2.) The behavior is not of a common and
trivial nature, such as picking at a wound or nail biting.
Non-Suicidal Self Injury
B. The intentional injury is associated with at least 2 of the
following:
1. Negative feelings or thoughts, such as depression,
anxiety, tension, anger, generalized distress, or selfcriticism, occurring in the period immediately prior to the
self-injurious act.
2. Prior to engaging in the act, a period of preoccupation
with the intended behavior that is difficult to resist.
3. The urge to engage in self-injury occurs frequently,
although it might not be acted upon.
4. The activity is engaged in with a purpose; this might be
relief from a negative feeling/cognitive state or
interpersonal difficulty or induction of a positive feeling
state. The patient anticipates these will occur either
during or immediately following the self-injury.