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WEEK 2 Communications Course Dr. Alex Alexander. Western Psychiatric Diagnostic Standards DSM-IV TR and Beyond Clinical Syndromes Developmental Disorders.

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Presentation on theme: "WEEK 2 Communications Course Dr. Alex Alexander. Western Psychiatric Diagnostic Standards DSM-IV TR and Beyond Clinical Syndromes Developmental Disorders."— Presentation transcript:

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 persons behavior is abnormal if it is statistically infrequent (deviates significantly from the average is above the cutoff point A persons 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 (cant 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 others 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 Others Perceptions Rosenhans 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 Rosenhans 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 Rosenhans 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.insane

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 individuals 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) 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 (Childrens 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 81-90Absent 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 ) 71-80If 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 ) 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 51-60Moderate 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 ) 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 ) 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 21-30Behavior 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 ) 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.


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