Transcript Course orientation

Course orientation:
Introduction to diagnosis in counseling
Class overview
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Introductions
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Syllabus & course expectations
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Getting started…
– Welcome to the DSM
– Role of diagnosis in counseling
– Risks & benefits of diagnosis
Diagnosis in counseling
DEFINE
ASSESSMENT (AX)
DIAGNOSIS (DX)
TREATMENT (TX)
Diagnosis in counseling
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Should counselors diagnose?
Is diagnosis consistent with “normal
and developmental” focus?
Is it possible to not diagnose?
Role of dx in counseling
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6.
Referral
Symptom identification
Diagnosis
Treatment planning
Treatment
Follow-up
In a nutshell:
AX  DX  TX
History of the DSM
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1840 – US Census adds “Idiocy/insanity”
1880 – US Census includes 7 categories
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Mania
Melancholia
Monomania
Paresis
Dementia
Dipsomania
Epilepsy
History of Diagnosis
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1917 – Census bureau & mental health
agencies collect info across hospitals
WWI – Army & VA needs better system
 10 psychoses
 9 psychoneuroses
 7 character/behavior/intelligence disorders
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WWII – Growing confusion
History of DSM-I
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Published 1952 w/ WHO’s ICD-6
108 types of disorders
130 pages
Narrative descriptions
Pyschodynamic assumptions
Disorder as reaction to other factors
Created for and by psychiatrists
History of DSM-II
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Published 1968 w/ ICD-8
185 types of disorders
Remained narrative
Remained psychodynamic
Moved away from “reaction” language
History of DSM-III
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Published in 1980 w/ ICD-9
265 disorders
Multiaxial format introduced
Specific criteria introduced
Movement to “atheoretical” base
Revised in 1987
290 Disorders
Homosexuality completely removed
History of the DSM-IV
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Published in 1994 w/ ICD-10
300 disorders
Revision criteria more stringent
Cultural upgrades
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Culture-specific text sections
Glossary of culture-bound syndromes
Outline for cultural formulation
Axis IV more inclusive
New V-codes
Text revision in 2000
DSM-IV-TR:
5 Axes (multiaxial)
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Axis I – Clinical d/o, other conditions
that may be a focus of clinical attention
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Axis II – Personality d/o & MR
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Axis III – General medical conditions
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Axis IV – Psychosocial and
environmental px
Axis V – Global assessment of
functioning
DSM 5
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Published May 2013 w/ ICD-10 CM
(scheduled for Oct. 2014)
Rationale:
– Better integration with ICD system
diagnostic coding
– Some symptom domains may involve
several diagnostic categories (“crosscutting”)
– Stimulate new clinical perspectives
DSM 5
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Developmental issues related to dx
Integration of advancements in
scientific research
Streamlined autism spectrum, mood
dx, substance dx
Specified neurocognitive dx
Change in conceptualizing personality
dx
DSM 5
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Included the more-global ICD WHO
Disability Assessment Schedule
(WHODAS) system for greater
accuracy
Included online supplemental info,
such as the Cultural Formation
Interview (CFI)
DSM 5 Today:
Information Provided
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Diagnostic features
Subtypes
Associated features and disorders
Specific culture and gender features
Prevalence
Course
Familial pattern
Differential diagnosis
Criteria
OUR FAMILIARITY
WITH “DISORDER”
The US population today
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Random, national sample
48% met DSM criteria at some point
– 21% met criteria for 1 disorder
– 13% met criteria for 2 disorders
– 14% met criteria for 3+ disorders
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29% met DSM criteria in past year
Less than 40% received treatment
(Kessler et al., 1994 as cited in Seligman, 2004)
DEFINE
“DISORDER”
VIP Point #1
“The symptoms cause clinically significant
distress or impairment in social,
occupational, or other important areas of
functioning.”
A “DISORDER” IS NOT
“Merely an expectable and culturally
sanctioned response to a particular event…”
“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”
(APA, 2000, xxxi)
VIP Point #2
There is ALWAYS more than
one diagnosis in DSM which
can explain any complaint!
Brainstorm:
Benefits of DSM Dx
Brainstorm:
Risks of DSM Dx
ETHICAL ISSUES (Braun &
Cox, 2005; Daniels, 2001)
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Informed consent
Confidentiality
Maintaining records
Competence
Integrity (i.e., no upcoding or downcoding)
Human welfare
Conflict of interest
Conditions of employment
Autonomy
INTENTIONAL
MISDIAGNOSIS
(Braun & Cox, 2005)
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Not all DSM codes are reimbursable
– e.g., v-codes, adjustment disorder, Axis II
personality disorders
– e.g., family or couples issues not in DSM
Upcoding
Downcoding
COMMON, UNETHICAL, & ILLEGAL
Additional, unintended consequences
FOR EXAMPLE
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You are completing your practicum in a counseling
program clinic. You are aware of the stigmas of
diagnoses, you are theoretically opposed to
diagnoses, and you want to serve your clients the
best you can. At the end of the semester you assign
V71.09 “no diagnosis” to all of your clients; after all
their distress was warranted. In addition, you assign
GAF scores based on the highest level of functioning
you have observed during your time.
Keeping it in perspective
“Become multilingual, accepting DSM as one
language exercise among many with all the
potential and limitations any language
possesses”
(Amundson, 1998, p. 2)
Keeping it in perspective
“As a text, it is simply a collection of
tales of suffering and complaint, a
compilation of information of (by its
own admission) often transient and
mutable quality. It is, at its best, an
historical and actuarial account,
providing some useful tips on how we
might arrange our thoughts and how
these thoughts can guide us in the
creation of a useful therapy.”
(Amundson, 1998, p. 3)
FOR NEXT WEEK…
Tab your DSMs
 No written homework
 Read, read, read
– Reading tips…
– Books & articles VIP
 Bring questions to class
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