The use of DSM-IV-TR and ICD-9-CM/ICD-10 in School Settings Alvin E. House, Ph.D. Department of Psychology Illinois State University

Goals of presentation Familiarity with basic components of DSM

Goals of presentation Familiarity with basic components of DSM Understanding the structure of DSM

Goals of presentation Familiarity with basic components of DSM Understanding the structure of DSM Introduction to the use of DSM

Goals of presentation Familiarity with basic components of DSM Understanding the structure of DSM Introduction to the use of DSM What’s not covered: Concerns about medical model Problems with categorical assessment Everything that is wrong with DSM

Goals of presentation What’s not covered: When do you play at a crooked card game?

Goals of presentation What’s not covered: When do you play at a crooked card game? When it’s the only game in town.

Goals of presentation What’s not covered: When do you play at a crooked card game? When it’s the only game in town. DSM-IV-TR/ICD-9-CM is the only game in town with regard to most potential sources of “recovered funds”, “third party carriers”, “reimbursement”, “funding”

Two metaphors for DSM-IV-TR A house

Two metaphors for DSM-IV-TR A house Oh, isn’t that a clever play on words. What, they’re both made from trees? I had to take the morning off for this?

Two metaphors for DSM-IV-TR A house “Constructed”, not “found”

Two metaphors for DSM-IV-TR A house Constructed, not “found” Constrained by nature of phenomenon

Two metaphors for DSM-IV-TR A house Constructed, not “found” Constrained by nature of phenomenon Utility rather than truth criterion for success

Two metaphors for DSM-IV-TR A house A language

Two metaphors for DSM-IV-TR A house A language used to communicate

Two metaphors for DSM-IV-TR A house A language used to communicate used to capture as much information about the case as possible

Two metaphors for DSM-IV-TR A house A language used to communicate used to capture as much information about the case as possible It’s less about getting the “right answer” than getting the clearest message across

The central role played by the examiner in DSM You are the most important element of a DSM-IV-TR diagnosis

The central role played by the examiner in DSM DSM is at heart a tool prepared by (mostly) physicians for the use of (mostly) other physicians

The central role played by the examiner in DSM You are the standard by which almost all judgments are made

The central role played by the examiner in DSM You are the standard by which almost all judgments are made Clinical judgment and responsibility are critical factors in DSM

The central role played by the examiner in DSM Sign/symptom Syndrome Disorder Disease

The central role played by the examiner in DSM Sign/symptom

The central role played by the examiner in DSM Sign/symptom Sign: objective manifestation of pathological condition observed by examiner (p. 827) Symptom: subjective manifestation of pathological condition reported by affected individual (p. 828)

Sources of confusion The complexity of the subject/task

Sources of confusion The complexity of the subject/task Errors in the references Very first case in DSM-IV-TR Case Studies shows a diagnosis of Mental Retardation on Axis I (p. 4)

Sources of confusion The complexity of the subject/task Errors in the references Ambiguities in the document What counts for a “setting” (besides “school” and “home”) for ADHD?

Sources of confusion The complexity of the subject/task Errors in the references Ambiguities in the document What counts for a “setting” (besides “school” and “home”) for ADHD? Does an Adjustment Disorder diagnosis take precedence over a thematic NOS diagnosis?

DSM-IV-TR Multiaxial Assessment Axis I Clinical Syndromes Other Conditions That May Be a Focus of Clinical Attention Axis II Mental Retardation Borderline Intellectual Functioning (not a mental disorder) Personality Disorders Personality Traits

DSM-IV-TR Multiaxial Assessment Continued Axis III General Medical Conditions Axis IV Psychosocial & Environmental Problems Axis V Global Assessment of Functioning (GAF) Scale

“DSM-IV-TR diagnosis” _ _ _ . _ _ Number The 3-5 digit number is the ICD-9-CM code for the condition or disorder being recorded ________ Disorder Title The condition or disorder being recorded (title, criterion set, other features) is an entry from DSM-IV-TR All DSM-IV-TR diagnoses are legitimate ICD-9-CM and ICD-10 diagnoses

DSM-IV Conceptualization of Mental Disorder “In DSM-IV, each of the mental disorders is conceptualized as a clinically significant behavioral or psychological syndrome or pattern that occurs in an individual and that is associated with present distress (e.g., a painful symptom) or disability (i.e., impairment in one or more important areas of functioning) or with a significantly increased risk of suffering death, pain, disability, or an important loss of freedom.” DMS-IV-TR, 2000, p. xxxi

DSM-IV Conceptualization of Mental Disorder Continued Clinically significant Syndrome/pattern Occurs in an individual Not expectable & culturally sanctioned response to a particular event Conflicts between individual and society are not mental disorders, unless the deviance or conflict is a symptom of a dysfunction in the individual Classified disorders that people have, not people

Clinical significance Distress

Clinical significance Distress Impairment

Clinical significance Distress Impairment In order to reduce false positive diagnoses almost all DSM-IV-TR diagnoses reiterate the distress/impairment criteria for a mental disorder

Clinical significance Distress Impairment In order to reduce false positive diagnoses almost all DSM-IV-TR diagnoses reiterate the distress/impairment criteria for a mental disorder An interesting exception is one of the few criterion changes made in the TR revision: Tourette’s Disorder

Use of DSM: multiple diagnoses DSM-IV-TR allows/encourages multiple diagnoses when the criteria for more than one diagnosis are met

Use of DSM: multiple diagnoses DSM-IV-TR allows/encourages multiple diagnoses when the criteria for more than one diagnosis are met; however, there are three general exceptions to control unbridled comorbidity

Use of DSM: multiple diagnoses Three general exceptions to multiple diagnoses: General Medical Condition/Substance Use

Use of DSM: multiple diagnoses Three general exceptions to multiple diagnoses: General Medical Condition/Substance Use “not due to the direct effects of a substance (e.g., drugs of abuse or medication) or a general medical condition.”

Use of DSM: multiple diagnoses Three general exceptions to multiple diagnoses: General Medical Condition/Substance Use Associated feature of a more pervasive disorder

Use of DSM: multiple diagnoses Three general exceptions to multiple diagnoses: General Medical Condition/Substance Use Associated feature of a more pervasive disorder “has never met the criteria for . . . .” “does not meet the criteria for . . . .” “does not occur exclusively during the course of . . . .”

Use of DSM: multiple diagnoses Three general exceptions to multiple diagnoses: Associated feature of a more pervasive disorder more pervasive diagnoses usually take precedence over more focal or narrow diagnoses

Importance of Associated Symptoms Associated symptoms are not part of a disorder’s definition or criterion set, but are common observed in the clinical presentation Associated symptoms tell you what else a given diagnosis will “account for” Associated symptoms help you decide if a single diagnosis is sufficient to explain the features of your case or if other diagnoses are needed

Course and Associated Symptoms An concurrent diagnosis of a pattern that normally would be as associated symptom of a more pervasive disorder, would suggest that you had established a history of the independent occurrence of that set of problems

Course and Associated Symptoms An concurrent diagnosis of a pattern that normally would be as associated symptom of a more pervasive disorder, would suggest that you had established a history of the independent occurrence of that set of problems For example, diagnosing Major Depressive Disorder, Single Episode and Generalized Anxiety Disorder Would suggest you had established a history of GAD when the Major Depressive Disorder wasn’t present

Course and Associated Symptoms An concurrent diagnosis of a pattern that normally would be as associated symptom of a more pervasive disorder, would suggest that you had established a history of the independent occurrence of that set of problems For example, diagnosing Major Depressive Disorder, Single Episode and Generalized Anxiety Disorder Or that you had made a mistake

Use of DSM: multiple diagnoses Three general exceptions to multiple diagnoses: Associated feature of a more pervasive disorder more pervasive diagnoses usually take precedence over more focal or narrow diagnoses Conduct Disorder has precedence over ODD

Use of DSM: multiple diagnoses Three general exceptions to multiple diagnoses: Associated feature of a more pervasive disorder more pervasive diagnoses usually take precedence over more focal or narrow diagnoses Conduct Disorder has precedence over ODD Mood Disorders have precedence over Anxiety Disorders

Use of DSM: multiple diagnoses Three general exceptions to multiple diagnoses: Associated feature of a more pervasive disorder more pervasive diagnoses usually take precedence over more focal or narrow diagnoses Conduct Disorder has precedence over ODD Mood Disorders have precedence over Anxiety Disorders Autistic Disorder has precedence over ADHD

Use of DSM: multiple diagnoses Three general exceptions to multiple diagnoses: Associated feature of a more pervasive disorder more pervasive diagnoses usually take precedence over more focal or narrow diagnoses General rule: skip first chapter and diagnose from front of text toward back

Use of DSM: multiple diagnoses Three general exceptions to multiple diagnoses: Associated feature of a more pervasive disorder usually take precedence over more focal or narrow diagnoses Occasional exception to this rule: when the less pervasive diagnosis becomes the focus of clinical attention (when there is a specific treatment plan)

Use of DSM: multiple diagnoses Three general exception of multiple diagnoses: General Medical Condition/Substance Use Associated feature of a more pervasive disorder Boundary conditions (clinical judgment required) “not better accounted for by . . . .”

Use of DSM: multiple diagnoses With more than one diagnosis, the principal diagnosis is the condition which leads to the evaluation or the referral for clinical services

Use of DSM: multiple diagnoses With more than one diagnosis, the principal diagnosis is the condition which leads to the evaluation or the referral for clinical services Unless otherwise indicated, the principal diagnosis is the first diagnosis on Axis I

Use of DSM: multiple diagnoses With more than one diagnosis, the principal diagnosis is the condition which lead to the evaluation or the referral for clinical services Unless otherwise indicated, the principal diagnosis is the first diagnosis on Axis I Axis I: Enuresis Axis II: Mental Retardation (reason for visit)

Use of DSM: multiple diagnoses With more than one diagnosis on either Axis I or Axis II, diagnoses should be listed within each axis in the order of clinical focus for attention or treatment

Use of DSM: the most important phrase in DSM “The essential features of . . . .”

Use of DSM: the most important phrase in DSM “The essential features of . . . .” The NOS (Not Otherwise Specified) diagnoses have two requirements:

Use of DSM: the most important phrase in DSM “The essential features of . . . .” The NOS (Not Otherwise Specified) diagnoses have two requirements: The condition must meet the criteria for a “mental disorder”

Use of DSM: the most important phrase in DSM “The essential features of . . . .” The NOS (Not Otherwise Specified) diagnoses have two requirements: The condition must meet the criteria for a “mental disorder” Significant function impairment or Significant personal distress or suffering

Use of DSM: the most important phrase in DSM “The essential features of . . . .” The NOS (Not Otherwise Specified) diagnoses have two requirements: The condition must meet the criteria for a “mental disorder” The condition must meet the “essential features” of the diagnosis being considered

Diagnostic Certainty

Specific Diagnosis Meets criteria for a mental disorder?......“Yes” Meets essential criteria for group?.........“Yes” Meets specific criteria for diagnosis?.....“Yes”

Specific Diagnosis, Provisional Meets criteria for a mental disorder?......“Yes” Meets essential criteria for group?.........“Yes” Meets specific criteria for diagnosis?.....“Not quite”

Categorical NOS Diagnosis Meets criteria for a mental disorder?......“Yes” Meets essential criteria for group?.........“Yes” Meets specific criteria for diagnosis?.....“No”

Mental Disorder NOS Meets criteria for a mental disorder?......“Yes” Meets essential criteria for group?.........“No” Meets specific criteria for diagnosis?.....“No”

799.9 Diagnosis Deferred Meets criteria for a mental disorder?......“Not sure” Meets essential criteria for group?.........“Not sure” Meets specific criteria for diagnosis?.....“No”

Use of DSM: subtypes & specifiers Subtypes: mutually exclusive and jointly exhaustive subgroupings within a diagnosis Specifiers are not mutually exclusive; provide for more homogeneous subgroupings of individuals who meet diagnostic criteria

Use of DSM: severity specifiers Severity: mild, moderate, severe Usually reflects the number of symptoms evident

Use of DSM: severity specifiers Severity: mild, moderate, severe Usually reflects the number of symptoms evident Mild: just meets or barely exceeds minimum requirement to support diagnosis

Use of DSM: severity specifiers Severity: mild, moderate, severe Usually reflects the number of symptoms evident Mild: just meets or barely exceeds minimum requirement to support diagnosis Severe: meets almost all or all diagnostic symptoms

Use of DSM: severity specifiers Severity: mild, moderate, severe Usually reflects the number of symptoms evident Mild: just meets or barely exceeds minimum requirement to support diagnosis Moderate: number of symptoms intermediate between mild and severe Severe: meets almost all or all diagnostic symptoms

Use of DSM: severity specifiers Severity: mild, moderate, severe Usually reflects the number of symptoms evident For some disorders specific criteria are provided for severity specifiers (e.g., Mental Retardation, Conduct Disorders, Manic Episode, Major Depressive Episode)

Use of DSM: course specifiers Course: (present), in partial remission, in full remission, prior history

Use of DSM: course specifiers Course: (present), in partial remission, in full remission, prior history In general “In Partial Remission” means full criteria were previously met and only some of the symptoms remain currently

Use of DSM: course specifiers Course: (present), in partial remission, in full remission, prior history In general “In Partial Remission” means full criteria were previously met and only some of the symptoms remain currently “In Full Remission” refers to complete absence of any current symptoms

Use of DSM: course specifiers In general “In Partial Remission” means full criteria were previously met and only some of the symptoms remain currently “In Full Remission” refers to complete absence of any current symptoms No absolute demarcation between In Full Remission and Recovered (when the disorder would no longer be noted)

Use of DSM: course specifiers Again, there are specific criteria for In Partial Remission and In Full Remission for some disorders (manic episode, major depressive disorder, substance abuse)

Use of DSM: “mental disorders” Axis I and Axis II comprise the “mental disorders”: diagnostic categories on both must meet the criteria for a mental disorder (V codes and personality traits do not meet criteria for mental disorders; these are listed on Axis I or Axis II also)

Use of DSM: conditions that are not “mental disorders” Other Conditions That May Be a Focus of Clinical Attention 316 Psychological Factor Affecting Medical Condition Medication-Induced Movement Disorders 995.2 Adverse Effects of Medication Not Otherwise Specified cont.

Use of DSM: conditions that are not “mental disorders” Other Conditions That May Be a Focus of Clinical Attention Relational Problems Problems Related to Abuse or Neglect Additional Conditions That May Be a Focus of Clinical Attention

Other Conditions that May Be a Focus of Clinical Attention Relational Problems V61.9 Relational Problem Related to a Mental Disorder or General Medical Condition V61.20 Parent-Child Relational Problem V61.10 Partner Relational Problem V61.8 Sibling Relational Problem V62.81 Relational Problem Not Otherwise Specified

Other Conditions that May Be a Focus of Clinical Attention Problems Related to Abuse or Neglect V61.21 Physical Abuse of Child 965.54 focus of clinical attention is victim V61.21 Sexual Abuse of Child 995.53 focus of clinical attention is victim V61.21 Neglect of Child 995.52 focus of clinical attention is victim there are also adult codes

Other Conditions that May Be a Focus of Clinical Attention Additional Conditions That May be a Focus of Clinical Attention V15.81 Noncompliance With Treatment V65.2 Malingering V71.01 Adult Antisocial Behavior V71.02 Child or Adolescent Antisocial Behavior V62.89 Borderline Intellectual Functioning IQ 71-84

Other Conditions that May Be a Focus of Clinical Attention Additional Conditions That May be a Focus of Clinical Attention 780.9 Age-Related Cognitive Decline V62.82 Bereavement V62.3 Academic Problem V62.2 Occupational Problem 313.82 Identity Problem V62.89 Religious or Spiritual Problem V62.4 Acculturation Problem V62.89 Phase of Life Problem

Additional Codes 300.9 Unspecified Mental Disorder V71.09 No Diagnosis or Condition on Axis I 799.9 Diagnosis or Condition Deferred on Axis I V71.09 No Diagnosis on Axis II 799.9 Diagnosis Deferred on Axis II

Use of DSM: “Disorders usually first evident . . . .” The first grouping of diagnoses in DSM-IV-TR is labeled, "Disorders Usually First Evident in Infancy, Childhood, or Adolescence." It is an unusual grouping because it is not thematically defined, as are most diagnostic groupings in DSM or etiologically defined (such as the OBS, general medical condition, and drug categories). Caution is necessary because:

Use of DSM: “Disorders usually first evident . . . .” Caution is necessary because: 1) not all children with mental disorders have mental disorders found in this first grouping

Use of DSM: “Disorders usually first evident . . . .” Caution is necessary because: 2) adults may be diagnosed with the disorders from the first grouping of diagnoses

Use of DSM: “Disorders usually first evident . . . .” Caution is necessary because: Also, there is no clear logical or thematic sequencing of the subsections Finally, recall that Mental Retardation (and Borderline Intellectual Functioning) are diagnosed on Axis II Most of the subsections in the first grouping of disorders have "The essential feature(s)"

Use of DSM: “Disorders usually first evident . . . .” Finally, recall that Mental Retardation (and Borderline Intellectual Functioning) are diagnosed on Axis II Most of the subsections in the first grouping of disorders have "The essential feature(s)"

Use of DSM: “Disorders usually first evident . . . .” It is therefore useful to train yourself not to speak or think of the first grouping as "the child section", "the child disorders", etc.

Use of DSM: Axis III Axis III: General Medical Conditions Physical disorders and conditions pertinent to understanding or managing the youth’s situation are recorded on Axis III May be judged to be etiologically relevant (dementia due to brain injury) or may be important to clinical management of case (diabetes precluding use of food reinforcer)

Use of DSM: Axis III Skolol (1989) discussed issue of use of Axis III by nonmedical mental health professionals He opined that notation on Axis III does not indicate diagnosis was made by person recording the multiaxial evaluation He suggests that nonmedical clinicians indicate the source of their information on Axis III

Use of DSM: Axis III Best Practice Recommendation: If you indicate an Axis III diagnosis always also indicate the source of the information or determination “mother reports child has juvenile onset diabetes” “genetic karyotype indicates trisomy 21” “seizure disorder diagnosed by child’s pediatrician”

Use of DSM: Axis IV Psychosocial and Environmental Problems problems with primary support group problems related to social environment educational problems occupational problems housing problems economic problems problems with access to health care services problems related to interaction with legal system other psychosocial and environmental problems

Use of DSM: Axis IV Psychosocial and Environmental Problems positive stressors are usually not listed usually past year is reference period may also be recorded on Axis I if focus of clinical attention

Use of DSM: Axis V Global Assessment of Functioning 0 - 100 rating of “overall level of functioning” “rated with respect only to psychological, social, and occupational [school] functioning” usually for current period; may also be made for other time periods (“highest level of functioning for at least a few months during the past year”)

Use of DSM: Axis V 100-91 superior functioning 90-81 no symptoms, good functioning 80-71 transient/expected reactions; slight impairment 70-61 mild symptoms or difficulty 60-51 moderate symptoms or moderate difficulty 50-41 serious symptoms or serious impairment 40-31 impaired reality testing/comm. or major impairment in several areas 30-21 impaired comm./judgment or inability to function 20-11 some danger to self or others or impaired hygiene 10-1 persistent danger to self or other or impaired self care or serious suicide attempt with clear expectation of death 0 inadequate information

The process of mental health diagnosis The fundamental questions: What are the problems?

The process of mental health diagnosis The fundamental questions: What are the problems? What are the domains involved?

The process of mental health diagnosis The fundamental questions: What are the problems? What are the domains involved? Cognitive Behavior Emotion Interpersonal Environmental

The process of mental health diagnosis The fundamental questions: What are the problems? What are the domains involved? Is there a Mental Disorder?

The process of mental health diagnosis The fundamental questions: What are the problems? What are the domains involved? Is there a Mental Disorder? What diagnosis best accounts for the available data?

The process of mental health diagnosis The fundamental questions: What are the problems? What are the domains involved? Is there a Mental Disorder? What diagnosis best accounts for the available data? Are there remaining important features of the case that need accounting for?

The process of mental health diagnosis The fundamental questions: What are the problems? What are the domains involved? Is there a Mental Disorder? What diagnosis best accounts for the available data? Are there remaining important features of the case that need accounting for? Are there any other diagnoses that need to be made?

Ethical & Legal Issues Mental health diagnosis using DSM-IV-TR is a process of professional, clinical judgment. The activity is regulated by law and by professional practice boards within states. Agencies, school units, and organizations may have additional or supplemental guidelines governing diagnostic practices but these cannot supercede the legal statutes of the state you practice in

Ethical & Legal Issues Diagnostic classification can have multiple, far ranging, and long lasting consequences for your clients and students

Ethical & Legal Issues Diagnostic consequences: Educational (stigma, accommodation) Vocational (ADHD and the military) Financial (mood diagnoses and insurance) Personal esteem and identity Treatment

Ethical & Legal Issues Maintain a clear definition of your professional role: Your job is to provide psychological services as indicated by your client’s situation--not to obtain health care benefits for the client or to recover fees for your agency

Ethical & Legal Issues We do not usually get into trouble for making mistakes

Ethical & Legal Issues We do not usually get into trouble for making mistakes We can and will get into trouble for not playing by the rules

Ethical & Legal Issues We do not usually get into trouble for making mistakes We can and will get into trouble for not playing by the rules Being “helpful” and fudging a diagnosis so your client can get coverage from their health care policy (that they are not actually entitled to) is viewed by the insurance company as “fraud” and treated as a crime

Ethical & Legal Issues Base your diagnosis on your best understanding of the data available regarding the youth’s behavior, feelings, thoughts, and adjustment If new data (or further consideration) changes your mind, change your diagnosis Practice in this manner and you will have no problems signing your name to your reports

Practice cases Take a few minutes and look at the material on the practice cases

DSM-IV ADHD “The essential feature of Attention-Deficit/Hyperactivity Disorder is a persistent pattern of inattention and/or hyperactivity-impulsivity that is more frequently displayed and more severe than is typically observed in individuals at a comparable level of development (Criterion A)” (p.85)

A(1) 6 or more have persisted for 6 month to a degree which is maladaptive and inconsistent with development level Inattention details/careless errors Difficulty sustaining attention Does not seem to listen Poor follow through (not oppositional) Difficulty organizing Dislikes/avoids tasks needing sustained effort Often loses things Easily distracted Often forgetful

A(2) Fidgets Leaves seat Often runs/climbs inappropriately Difficulty playing quietly Often “on the go”, as if “driven by a motor” Talks excessively Blurts out answers Difficulty waiting turn Interrupts/intrudes on others

Some symptoms have caused impairment before age 7 Some impairment from symptoms in 2 or more settings Clinically significant impairment in social, academic, or occupational functioning Does not occur exclusively during course of: Pervasive developmental disorder Schizophrenia Psychotic Disorder Not better accounted for by another Mental Disorder

Sally

Axis I: Attention-Deficit/Hyperactivity Disorder, Predominantly Inattentive Type Failure to attend/careless errors Difficulty sustaining attention Doesn’t seem to listen Doesn’t follow through Difficulty organizing Loses things Easily distracted Forgetful

Reading Disorder Reading achievement below expectation Interferes with academic achievement [poor spelling, difficulty sounding words out, history of speech delay, early articulation problems]

Axis II: No Disorder on Axis II Axis III: No medical problems reported Axis IV: Academic problems Problems with peer relationships Axis V: 55-60

Axis II: V71.09 No disorder on Axis II 314.00 Attention-Deficit/Hyperactivity Disorder, Predominantly Inattentive Type 315.00 Reading Disorder Axis II: V71.09 No disorder on Axis II Axis III: No medical problems reported Axis IV: Academic problems Problems with peer relationships Axis V: Global Assessment of Functioning: 60

George

Axis I: Tourette’s Disorder Motor and vocal tics Two year duration Attention-Deficit/Hyperactivity Disorder, Predominantly Hyperactive- Impulsive type Fidgets Problems remaining seated Climbs excessively Difficulty engaging in quiet activities “Driven” Talks excessively Blurts out answers Difficulty awaiting turn Interrupts others

Axis II: No Disorder on Axis II Axis III: Treatment with CNS stimulant Axis IV: Problems with peer relationships Axis V: 45-60

Axis II: V71.09 No disorder on Axis II 307.23 Tourette’s Disorder 314.01 Attention-Deficit/Hyperactivity Disorder, Predominantly Hyperactive-Impulsive Type Axis II: V71.09 No disorder on Axis II Axis III: Treatment with CNS stimulant Axis IV: Problems with peer relationships Axis V: Global Assessment of Functioning: 53 [45-60]

Maude

Axis I: Oppositional Defiant Disorder Loses temper Argues with adults Noncompliance Provokes others Blames others Easily annoyed Angry/resentful Vindictive

Axis II: No disorder on Axis II Axis III: No medical problems reported Axis IV: Problems with peer relationships Problems with parents Axis V: 45-60

Axis I: 313.81 Oppositional Defiant Disorder Axis II: V71.09 No disorder on Axis II Axis III: Problems with peer relationships Problems with parents Axis IV: Global Assessment of Functioning: 52 [45-60]

Lucy

Axis I: Alcohol Dependence, With Physiological Dependence Withdrawal Increased drinking Unsuccessful efforts to cut down Great deal of time spent Activities given up

Axis II: No disorder on Axis II Axis III: No medical problems reported Axis IV: Other psychosocial problems: adjustment to adolescence and high school Axis V: 35-45

Axis I: 303.90 Alcohol Dependence, With Physiological Dependence Axis II: V71.09 No disorder on Axis II Axis III: No medical problems reported History of withdrawal symptoms reported

Axis IV: Other psychological problems: adjustment to adolescence and high school Axis V: Global Assessment of Functioning: 40 [35-45]

Fred

Axis I: Specific Phobia, Blood-Injury Type Fear: marked, persistent, excessive, unreasonable Exposure produces anxiety response Insight Avoidance Duration of avoidance 12 months Not better accounted for [family history of anxiety problems]

Axis II: No disorder on Axis II Axis III: Dental problems reported Axis IV: Problems with access to health care Axis V: 45

Axis I: 309.29 Specific Phobia, Blood-Injury Type Axis II: V71.09 No disorder on Axis II Axis III: Dental problems reported Axis IV: Problems with access to health care Axis V: Global Assessment of Functioning: 45

Danny

Axis I: Dysthymic Disorder Depressed several years, without sustained relief Low self-esteem Feelings of hopelessness No Major Depressive Episodes, no Manic Episodes, no Hypomanic Episodes, not during Psychotic disorder, not result of substance or general medical condition Clinically significant distress [suicidal] Not better accounted for History of alcohol abuse History of cannabis abuse

Axis II: No disorder on Axis II Axis III: No medical problems reported [family history of mood disorder] Axis IV: None Axis V: 15

Axis I: 300.4 Dysthymic Disorder Axis II: V71.09 No disorder on Axis II Axis III: No medical problems reported [family history of mood disorder] Axis IV: None Axis V: Global Assessment of Functioning: 15

Take Home Points DSM-IV-TR is a categorical classification system of mental disorders and other clinically relevant phenomena In DSM-IV-TR mental disorders are recurrent patterns of behavior (syndromes) which persist over at least minimal periods of time and cause clinically significant distress to the client of impairment of the client’s adjustment and functioning

Take Home Points Continued The practicing clinician makes the determination as to whether symptoms are present and whether the client’s distress or impairment meets the criterion of clinically significant; she/he assumes primary responsibility for these decisions and is accorded a great deal of confidence within this framework

Take Home Points Continued DSM-IV-TR allows/encourages multiple diagnoses in order to capture as much information as possible about the client, their problems, and their situation; with certain restrictions More pervasive diagnoses usually take precedence over less pervasive diagnoses Unless the less pervasive diagnosis is independent of the more pervasive diagnosis Unless, in some instance, the less pervasive diagnosis become the focus of a treatment plan

Take Home Points Continued Medical and substance induced mental disorders take precedence over other DSM diagnoses There are a number of issues of ambiguity that are not resolved by the available texts There are few “child” or “adult” specific diagnoses and the first chapter should not be considered the “child” section of DSM

Take Home Points Continued Most specific diagnoses take precedence over Adjustment Disorder diagnoses (regardless of etiology); Adjustment Disorder diagnoses (if criteria are met) appear to take precedence of NOS diagnoses DSM-IV-TR allows the clinician to indicate their level of confidence/certainty regarding the diagnosis made

Take Home Points Continued Diagnoses should always and only be based on your best understanding of the data available regarding the youth’s behavior, feelings, thoughts, and adjustment

QUESTIONS?