1. WEEK 2 Communications Course
Dr. Alex Alexander

2. Western Psychiatric Diagnostic Standards DSM-IV TR and Beyond
Clinical Syndromes
Developmental Disorders
Personality Disorders

3. The Axes of Diagnosis
Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM- IV TR)
Axes I-IV
Facilitates Comprehensive Diagnostic Picture

4. What Does Comprehensive Mean?
Encompasses Mental, Medical Psychosocial, Environmental, Social, and Functionality
Single diagnosis might miss these
Uses BIOPSYCHOSOCIAL model
How can this be beneficial or deleterious?

5. Diagnosis of Mental Disorders is Subjective
Homosexuality was a mental disorder until 1973
Koro (shook yong-traditional chinese)- In the 4th edition. Intense fear that genitals will shrink up/draw up into abdomen and cause death
Windigo- Intense fear of being turned into a cannibal by a supernatural monster

6. Definitions of Abnormal Behavior
Conformity to norms: Statistical Infrequency or Violation of Social Norms
Subjective distress
Disability or dysfunction

7. Conformity to norms: Statistical Infrequency or Violation of Social Norms
A person’s behavior is abnormal if it is statistically infrequent (deviates significantly from the average is above the “cutoff point”
A person’s behavior is abnormal if it is very unusual

8. Conformity to norms: Statistical Infrequency or Violation of Social Norms
Advantages
Cutoff points are quantitative
Social norms seem obvious and have intuitive appeal
Disadvantages
There are few guidelines for establishing cutoff scores
Number of deviations
Cultural relativity

9. Subjective distress
Are behaviors or symptoms abnormal if they cause the person distress?

10. Subjective distress
Advantages
Individuals who may be distressed “inside” but not outwardly suffering, can be identified (can’t tell by looking)
Disadvantages
Not all pathology causes distress (e.g. conduct disorder or psychoses)
Difficult to determine the amount of subjective distress is needed to be labeled abnormal?

11. Disability or dysfunction
A behavior is abnormal if it creates some degree of social (interpersonal) or occupational problems

12. Disability or Dysfunction
Advantages
Requires little inference
These type of problems often prompt treatment seeking
Disadvantages
Difficulty establishing standards for occupational or social dysfunction

13. Diagnostic and Statistical Manual-IV-TR
…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.

14. Multiaxial Assessment
Axis 1 - Clinical disorders (e.g., mood & anxiety disorders)
Axis 2 - Personality disorders (e.g., narcissism, antisocial) & mental retardation
Axis 3 - Medical (physical) conditions influencing Axis 1 & 2 disorders
Axis 4 - Psychosocial & environmental stress influencing Axis 1 & 2 disorders
Axis 5 - Global Assessment of Function - highest current functioning

15. Diagnosis: Positive Aspects
Facilitates communication (verbal shorthand)
Ensures comparability among identified patients
Promotes research on diagnostic features,
etiology and treatment

16. Diagnosis: Negative Aspects
Boundaries between disorders are often fuzzy
Gender bias in application of diagnostic labels
Negative effects of labeling on other’s perceptions
Negative effects of labeling on self-concept

17. Gender Bias in Diagnoses
The gender of the patient influences the diagnosis, despite the presentation of equivalent symptoms

18. Negative Effects on Other’s Perceptions
Rosenhan’s On Being Sane in Insane Places (1973)
Experimental Method - Part I
8 subjects
Admitted to Psychiatric Hospitals on the basis of fake symptoms
Upon admission they began to act normally

19. Rosenhan’s Procedure Pseudo-patient complained hearing voices
No other alternation of history
Everyone admitted with schiz. Diagnosis
After admission acted normally
Had to get out by convincing staff they were rehabilitated

20. Rosenhan’s Results Pseudopatients were never detected
Each was discharged with diagnosis of “schizophrenia in remission”
Hospitalization varied from 7 to 52 days
Common for other patients to detect their sanity

21. Implications from Rosenhan
Diagnoses carry personal, legal and social stigma
Results suggest that diagnostic labels create a negative lens for viewing the person
Diagnoses can lower expectations from others and from self

22. Part 2 of Rosenhan
The second part involved asking staff at a psychiatric hospital to detect non-existent "fake" patients. No fake patients were sent, yet the staff falsely identified large numbers of ordinary patients as impostors.
The study concluded, "It is clear that we cannot distinguish the sane from the insane in psychiatric hospitals" and also illustrated the dangers of dehumanization and labeling in psychiatric institutions. It suggested the use of community mental health facilities which concentrated on specific problems and behaviors rather than psychiatric labels.

23. Class Activity
For each of the following words, write a sentence that describes an experience you had that is associated with that respective word…
Train
Ice
House
Meeting
Machine
Road
Rain
Tunnel

24. Class Activity
For each experience you wrote down, rate whether the experience was pleasant or unpleasant
After you have rated all experiences, tally the total number of pleasant and unpleasant experiences

25. Class Activity How have you felt today?
Happy? Sad? Somewhat depressed?
The number of pleasant vs. unpleasant experiences you recalled should be related to your mood today.
When we are depressed, we remember more unpleasant than pleasant events.

26. Multiaxial Assessment (again)
Axis 1 - Clinical disorders (e.g., mood & anxiety disorders)
Axis 2 - Personality disorders (e.g., narcissism, antisocial) & mental retardation
Axis 3 - Medical (physical) conditions influencing Axis 1 & 2 disorders
Axis 4 - Psychosocial & environmental stress influencing Axis 1 & 2 disorders
Axis 5 - Global Assessment of Function - highest current functioning

27. Axis I Clinical Disorders Other Conditions That May Be a Focus of Clinical Attention
All of the various disorders except Personality Disorders and Mental Retardation
If more than one Axis I diagnosis, all should be reported
Best to also label the “principal diagnosis” or “reason for visit”
If more info is needed to make an Axis I diagnosis, code: Deferred (799.9)
If no Axis I diagnosis is warranted, code: None (V71.09)

28. Axis II Personality Disorders Mental Retardation
Axis II notes “prominent maladaptive personality features and defense mechanisms”.
Having a separate axis for these concerns “ensures that consideration will be given to the possible presence of Personality Disorders and Mental Retardation” that would otherwise be overlooked in a single-axis diagnostic schema.
Note: Borderline Intellectual Functioning is also coded on Axis II
Even if Axis I diagnoses are “more florid” Axis II diagnoses are equally important.
If more info is needed to make an Axis II diagnosis, code: Deferred (799.9)
If no Axis II diagnosis is warranted, code: None (V71.09)

29. Severity
For Axis I and Axis II, can code severity either in some diagnostic categories (e.g., mental retardation) or using specifiers:
Mild: meets criteria for the diagnosis; however, few additional symptoms
Moderate: “between Mild and Severe”
Severe: either has many more symptoms than required for a diagnosis, some of the symptoms are particularly severe (e.g., suicide attempt), or daily functioning (school, work, family) is severely affected.
Can also note the following for Axis I or Axis II:
In Partial Remission: patient no longer meets full diagnostic criteria; some symptoms may still remain.
In Full Remission: patient has been free of symptoms for an extended period of time.
Prior History: patient no longer meets criteria for this diagnosis; however, it is clinically prudent to include this diagnosis.

30. Rule - Outs
Suppose you assess a patient and believe a diagnosis is warranted; however, you do not have enough assessment data to confirm the diagnosis.
However, to not diagnose this “hunch” would not communicate the clinical picture of the patient effectively.
You may consider using a “rule-out” diagnosis: R/O in place of the actual diagnosis.

31. Axis III General Medical Conditions
These should be “potentially relevant to the understanding or management of the individual’s mental disorder.”
Primary purpose of Axis III:
“to encourage thoroughness in evaluation”
“to enhance communication among health care providers”
Differential diagnostic issue:
If a general medical condition is a direct physiologic cause of a mental disorder, it is coded on Axis I and Axis III.
Axis I: Mood Disorder Due to Hypothyroidism
Axis III: Hypothyroidism

32. Axis III General Medical Conditions
Medical conditions can influence choice in pharmacotherapy.
If multiple diagnoses are present on Axis III, code them all.
If no diagnosis is present, code “None”.
Notes:
Numerical codes for Axis III come from the ICD-9 (or ICD-10)
No numerical code for “None”.

33. Axis IV Psychosocial and Environmental Problems
Biopsychosocial model:
Axis III + Axis I + Axis II + Axis IV
These are typically a negative life event, an environmental difficulty or deficiency, familial or interpersonal stress, poor social support or personal resources.

34. Axis IV Psychosocial and Environmental Problems
Examples:
Problems with the primary support group
Death of a family member
Problems related to the social environment
Difficulty with acculturation
Educational problems
Discord with teachers
Occupational problems
Unemployment

35. Axis IV Psychosocial and Environmental Problems
Examples:
Housing problems
Homelessness
Economic problems
Insufficient welfare support
Problems with access to health care services
Inadequate health insurance
Problems related to interaction with the legal system
Incarceration
Other psychosocial and environmental problems
War, natural disasters

36. Axis V Global Assessment of Functioning
Clinical judgment involved in Axis V
“How is the patient doing, overall.”
100-point scale, divided into 10 ranges
GAF – adult scale
CGAS (Children’s Global Assessment Scale) – GAF adapted for children
Can also report the time period that the rating encompasses:
Current, highest over past year, at admission, at discharge

37. Global Assessment of Functioning
Superior functioning in a wide range of activities, life's problems never seem to get out of hand, is sought out by others because of his or her many positive qualities. No symptoms
81-90 Absent or minimal symptoms ( e.g., mild anxiety before an exam ), good functioning in all areas, interested and involved in a wide range of activities, socially effective, generally satisfied with life, no more than everyday problems or concerns ( e.g., an occasional argument with family members )
71-80 If symptoms are present, they are transient and expectable reactions to psychosocial. stressors ( e.g., difficulty concentrating after family argument ); no more than slight impairment in social occupational, or school functioning ( e.g., temporarily falling behind in schoolwork ).
61-70 Some mild symptoms ( e.g., depressed mood and mild insomnia ) OR some difficulty in social occupational, or school functioning (e.g., occasional truancy or theft within the household ), but generally functioning pretty well, has some meaningful interpersonal relationships.

38. GAF
51-60 Moderate symptoms ( e.g., flat affect and circumstantial speech, occasional panic attacks ) OR moderate difficulty in social, occupational, or school functioning ( e.g., few friends, conflicts with peers or co-workers ).
41-50 Severe symptoms ( e.g., suicidal ideation, severe obsessional rituals, frequent shoplifting ) OR any serious impairment in social, occupational or school functioning ( e,g., no friends, unable to keep a job ).
31-40 Some impairment in reality testing or communication ( e.g., speech is at times illogical, obscure, or irrelevant ) OR major impairment in several areas, such as work or school, family relations, judgment, thinking, or mood ( e.g., depressed man avoids friends, neglects family, and is unable to work; child frequently beats up younger children, is defiant at home, and is failing at school ).

39. GAF
21-30 Behavior is considerably influenced by delusions or hallucinations OR serious impairment in communication or judgment ( e.g., sometimes incoherent, acts grossly inappropriately, suicidal preoccupation ) OR inability to function in almost all areas ( e.g.,stays in bed all day, no job, home, or friends ).
Some danger of hurting self or others ( e .g., suicidal attempts without clear expectation of death; frequently violent; manic excitement ) OR occasionally fails to maintain minimal personal hygiene ( e.g., smears feces ) OR gross impairment in communication ( e.g., largely incoherent or mute ).
1-10 Persistent danger of severely hurting self or others ( e.g., recurrent violence ) OR persistent inability to maintain minimal personal hygiene OR serious suicidal act with clear expectation of death.

40. Example Axial Diagnosis
Axis I: Bipolar II Disorder, Early Onset.
Axis I: Bulimia Nervosa, Nonpurging Type.
Axis II: Dependent Personality Disorder
Axis III: Complete Atrioventricular Block
Axis IV: Child abuse victim, unemployment
Axis V: 28

41. Definition of Crazy?
Doing the same things over and over and expecting different results.