3The Axes of DiagnosisDiagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM- IV TR)Axes I-IVFacilitates Comprehensive Diagnostic Picture
4What Does Comprehensive Mean? Encompasses Mental, Medical Psychosocial, Environmental, Social, and FunctionalitySingle diagnosis might miss theseUses BIOPSYCHOSOCIAL modelHow can this be beneficial or deleterious?
5Diagnosis of Mental Disorders is Subjective Homosexuality was a mental disorder until 1973Koro (shook yong-traditional chinese)- In the 4th edition. Intense fear that genitals will shrink up/draw up into abdomen and cause deathWindigo- Intense fear of being turned into a cannibal by a supernatural monster
6Definitions of Abnormal Behavior Conformity to norms: Statistical Infrequency or Violation of Social NormsSubjective distressDisability or dysfunction
7Conformity 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
8Conformity to norms: Statistical Infrequency or Violation of Social Norms AdvantagesCutoff points are quantitativeSocial norms seem obvious and have intuitive appealDisadvantagesThere are few guidelines for establishing cutoff scoresNumber of deviationsCultural relativity
9Subjective distressAre behaviors or symptoms abnormal if they cause the person distress?
10Subjective distressAdvantagesIndividuals who may be distressed “inside” but not outwardly suffering, can be identified (can’t tell by looking)DisadvantagesNot all pathology causes distress (e.g. conduct disorder or psychoses)Difficult to determine the amount of subjective distress is needed to be labeled abnormal?
11Disability or dysfunction A behavior is abnormal if it creates some degree of social (interpersonal) or occupational problems
12Disability or Dysfunction AdvantagesRequires little inferenceThese type of problems often prompt treatment seekingDisadvantagesDifficulty establishing standards for occupational or social dysfunction
13Diagnostic 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.
15Diagnosis: Positive Aspects Facilitates communication (verbal shorthand)Ensures comparability among identified patientsPromotes research on diagnostic features,etiology and treatment
16Diagnosis: Negative Aspects Boundaries between disorders are often fuzzyGender bias in application of diagnostic labelsNegative effects of labeling on other’s perceptionsNegative effects of labeling on self-concept
17Gender Bias in Diagnoses The gender of the patient influences the diagnosis, despite the presentation of equivalent symptoms
18Negative Effects on Other’s Perceptions Rosenhan’s On Being Sane in Insane Places (1973)Experimental Method - Part I8 subjectsAdmitted to Psychiatric Hospitals on the basis of fake symptomsUpon admission they began to act normally
19Rosenhan’s Procedure Pseudo-patient complained hearing voices No other alternation of historyEveryone admitted with schiz. DiagnosisAfter admission acted normallyHad to get out by convincing staff they were rehabilitated
20Rosenhan’s Results Pseudopatients were never detected Each was discharged with diagnosis of “schizophrenia in remission”Hospitalization varied from 7 to 52 daysCommon for other patients to detect their sanity
21Implications from Rosenhan Diagnoses carry personal, legal and social stigmaResults suggest that diagnostic labels create a negative lens for viewing the personDiagnoses can lower expectations from others and from self
22Part 2 of RosenhanThe 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.
23Class ActivityFor each of the following words, write a sentence that describes an experience you had that is associated with that respective word…TrainIceHouseMeetingMachineRoadRainTunnel
24Class ActivityFor each experience you wrote down, rate whether the experience was pleasant or unpleasantAfter you have rated all experiences, tally the total number of pleasant and unpleasant experiences
25Class 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.
27Axis I Clinical Disorders Other Conditions That May Be a Focus of Clinical Attention All of the various disorders except Personality Disorders and Mental RetardationIf more than one Axis I diagnosis, all should be reportedBest 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)
28Axis 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 IIEven 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)
29SeverityFor 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 symptomsModerate: “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.
30Rule - OutsSuppose 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.
31Axis 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 HypothyroidismAxis III: Hypothyroidism
32Axis 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”.
33Axis IV Psychosocial and Environmental Problems Biopsychosocial model:Axis III + Axis I + Axis II + Axis IVThese are typically a negative life event, an environmental difficulty or deficiency, familial or interpersonal stress, poor social support or personal resources.
34Axis IV Psychosocial and Environmental Problems Examples:Problems with the primary support groupDeath of a family memberProblems related to the social environmentDifficulty with acculturationEducational problemsDiscord with teachersOccupational problemsUnemployment
35Axis IV Psychosocial and Environmental Problems Examples:Housing problemsHomelessnessEconomic problemsInsufficient welfare supportProblems with access to health care servicesInadequate health insuranceProblems related to interaction with the legal systemIncarcerationOther psychosocial and environmental problemsWar, natural disasters
36Axis V Global Assessment of Functioning Clinical judgment involved in Axis V“How is the patient doing, overall.”100-point scale, divided into 10 rangesGAF – adult scaleCGAS (Children’s Global Assessment Scale) – GAF adapted for childrenCan also report the time period that the rating encompasses:Current, highest over past year, at admission, at discharge
37Global 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 symptoms81-90 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.
38GAF51-60 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 ).
39GAF21-30 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.