WEEK 2 Communications Course

WEEK 2 Communications Course • Dr. Alex Alexander

Western Psychiatric Diagnostic StandardsDSM-IV TR and Beyond • Clinical Syndromes • Developmental Disorders • Personality Disorders

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

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?

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

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

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

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

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

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?

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

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

Diagnostic and Statistical Manual-IV-TR • …The most widely accepted definition used in DSM-IV-TR describes behavioral, emotional or cognitive dysfunctions that areunexpected in their cultural context and associated with personal distress or substantial impairment in functioning.

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

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

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

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

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

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

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

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

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.

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

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

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.

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

Axis IClinical DisordersOther 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)

Axis IIPersonality DisordersMental 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)

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.

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.

Axis IIIGeneral 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

Axis IIIGeneral 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”.

Axis IVPsychosocial 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.

Axis IVPsychosocial 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

Axis IVPsychosocial 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

Axis VGlobal 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

Global Assessment of Functioning • 91-100Superior 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 ). • 61-70Some 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.

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 ). • 41-50Severe 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 ). • 31-40Some 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 ).

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 ). • 11-20 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.

Example Axial Diagnosis • Axis I: 296.84 Bipolar II Disorder, Early Onset. • Axis I: 307.51 Bulimia Nervosa, Nonpurging Type. • Axis II: 301.6 Dependent Personality Disorder • Axis III: 426.00 Complete Atrioventricular Block • Axis IV: Child abuse victim, unemployment • Axis V: 28

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

WEEK 2 Communications Course