1. Course orientation: Introduction to diagnosis in counseling

2. Class overview Introductions Introductions Syllabus & course expectations Syllabus & course expectations Getting started… Getting started… –Welcome to the DSM –Role of diagnosis in counseling –Risks & benefits of diagnosis

3. Diagnosis in counseling DEFINE ASSESSMENT (AX) DIAGNOSIS (DX) TREATMENT (TX)

4. Diagnosis in counseling Should counselors diagnose? Should counselors diagnose? Is diagnosis consistent with “normal and developmental” focus? Is diagnosis consistent with “normal and developmental” focus? Is it possible to not diagnose? Is it possible to not diagnose?

5. Role of dx in counseling 1. Referral 2. Symptom identification 3. Diagnosis 4. Treatment planning 5. Treatment 6. Follow-up In a nutshell: AX  DX  TX

6. History of the DSM 1840 – US Census adds “Idiocy/insanity” 1840 – US Census adds “Idiocy/insanity” 1880 – US Census includes 7 categories 1880 – US Census includes 7 categories  Mania  Melancholia  Monomania  Paresis  Dementia  Dipsomania  Epilepsy

7. History of Diagnosis  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  WWII – Growing confusion

8. History of DSM-I Published 1952 w/ WHO’s ICD-6 Published 1952 w/ WHO’s ICD-6 108 types of disorders 108 types of disorders 130 pages 130 pages Narrative descriptions Narrative descriptions Pyschodynamic assumptions Pyschodynamic assumptions Disorder as reaction to other factors Disorder as reaction to other factors Created for and by psychiatrists Created for and by psychiatrists

9. History of DSM-II  Published 1968 w/ ICD-8  185 types of disorders  Remained narrative  Remained psychodynamic  Moved away from “ reaction ” language

10. History of DSM-III  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

11. History of the DSM-IV  Published in 1994 w/ ICD-10  300 disorders  Revision criteria more stringent  Cultural upgrades  Culture-specific text sections  Glossary of culture-bound syndromes  Outline for cultural formulation  Axis IV more inclusive  New V-codes Text revision in 2000 Text revision in 2000

12. DSM-IV-TR: 5 Axes (multiaxial) Axis I – Clinical d/o, other conditions that may be a focus of clinical attention Axis I – Clinical d/o, other conditions that may be a focus of clinical attention Axis II – Personality d/o & MR Axis II – Personality d/o & MR Axis III – General medical conditions Axis III – General medical conditions Axis IV – Psychosocial and environmental px Axis IV – Psychosocial and environmental px Axis V – Global assessment of functioning Axis V – Global assessment of functioning

13. DSM 5 Published May 2013 w/ ICD-10 CM (scheduled for Oct. 2014) Published May 2013 w/ ICD-10 CM (scheduled for Oct. 2014) Rationale: Rationale: –Better integration with ICD system diagnostic coding –Some symptom domains may involve several diagnostic categories (“cross- cutting”) –Stimulate new clinical perspectives

14. DSM 5 Developmental issues related to dx Developmental issues related to dx Integration of advancements in scientific research Integration of advancements in scientific research Streamlined autism spectrum, mood dx, substance dx Streamlined autism spectrum, mood dx, substance dx Specified neurocognitive dx Specified neurocognitive dx Change in conceptualizing personality dx Change in conceptualizing personality dx

15. DSM 5 Included the more-global ICD WHO Disability Assessment Schedule (WHODAS) system for greater accuracy 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) Included online supplemental info, such as the Cultural Formation Interview (CFI)

16. DSM 5 Today: Information Provided Diagnostic features Diagnostic features Subtypes Subtypes Associated features and disorders Associated features and disorders Specific culture and gender features Specific culture and gender features Prevalence Prevalence Course Course Familial pattern Familial pattern Differential diagnosis Differential diagnosis Criteria Criteria

17. OUR FAMILIARITY WITH “DISORDER”

18. The US population today Random, national sample Random, national sample 48% met DSM criteria at some point 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 29% met DSM criteria in past year 29% met DSM criteria in past year Less than 40% received treatment Less than 40% received treatment (Kessler et al., 1994 as cited in Seligman, 2004)

19. DEFINE “DISORDER”

20. VIP Point #1 “The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.”

21. “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) A “DISORDER” IS NOT

22. VIP Point #2 There is ALWAYS more than one diagnosis in DSM which can explain any complaint!

23. Brainstorm: Benefits of DSM Dx

24. Brainstorm: Risks of DSM Dx

25. ETHICAL ISSUES (Braun & Cox, 2005; Daniels, 2001) Informed consent Informed consent Confidentiality Confidentiality Maintaining records Maintaining records Competence Competence Integrity (i.e., no upcoding or downcoding) Integrity (i.e., no upcoding or downcoding) Human welfare Human welfare Conflict of interest Conflict of interest Conditions of employment Conditions of employment Autonomy Autonomy

26. INTENTIONAL MISDIAGNOSIS (Braun & Cox, 2005) Not all DSM codes are reimbursable 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 Upcoding Downcoding Downcoding COMMON, UNETHICAL, & ILLEGAL COMMON, UNETHICAL, & ILLEGAL Additional, unintended consequences Additional, unintended consequences

27. FOR EXAMPLE 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. 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.

28. 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)

29. 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. ” “ 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)

30. FOR NEXT WEEK… Tab your DSMs Tab your DSMs No written homework No written homework Read, read, read Read, read, read –Reading tips… –Books & articles VIP Bring questions to class Bring questions to class