Lecture Overview

1. Clinical Diagnosis 1 Lecture Overview History of clinical diagnosis Criticisms of clinical diagnosis? Objectives of our current diagnostic system Basic features of the DSM-IV Major categories of mental disorders Empirical dimensional approach to classification (�quantitative taxonomy�)

2. Clinical Diagnosis 2 History Pre DSM DSM-I (1952) DSM-II (1968) DSM-III (1980) DSM-III-R (1987) DSM-IV (1994) DSM-IV-TR (2003) History of psychological diagnosis dates back as far as 2600 B.C. when the symptoms of melancholia and hysteria first appeared in the Egyptian literature. The first official system for classifying mental disorders in the US was in 1840. It had only one category for all mental disorders (insane). Forty years later mental disorders were subdivided into 7 categories including mania, melancholia, monomania, paresis, dementia, dipsomania, and epilepsy. In 1952 DSM I was published. It was the first systematic classification of mental disorders. DSM-I contain a glossary of descriptions of the diagnostic categories. The term reaction was used throughout reflecting the influence of Adolf Meyer's psychobiological view that mental disorders represented REACTIONS of the personality to psychological, social, and biological factors. In 1968 DSM II was published. It attempted to correspond with ICD-8. It was similar to DSM-I with the exception that the word �reaction� was dropped. This classification was based on the mental disorders section of ICD-8 from the World Health Organization. DSM-II did not use the term reaction and used diagnostic terms that by and large did not imply a particular theoretical framework. Work on DSM III began in 1974 and it was completed and published in 1980. Unlike its predecessors, DSM III included a number of major advances and redefinition of various mental disorders which we'll be discussing shortly.History of psychological diagnosis dates back as far as 2600 B.C. when the symptoms of melancholia and hysteria first appeared in the Egyptian literature. The first official system for classifying mental disorders in the US was in 1840. It had only one category for all mental disorders (insane). Forty years later mental disorders were subdivided into 7 categories including mania, melancholia, monomania, paresis, dementia, dipsomania, and epilepsy. In 1952 DSM I was published. It was the first systematic classification of mental disorders. DSM-I contain a glossary of descriptions of the diagnostic categories. The term reaction was used throughout reflecting the influence of Adolf Meyer's psychobiological view that mental disorders represented REACTIONS of the personality to psychological, social, and biological factors. In 1968 DSM II was published. It attempted to correspond with ICD-8. It was similar to DSM-I with the exception that the word �reaction� was dropped. This classification was based on the mental disorders section of ICD-8 from the World Health Organization. DSM-II did not use the term reaction and used diagnostic terms that by and large did not imply a particular theoretical framework. Work on DSM III began in 1974 and it was completed and published in 1980. Unlike its predecessors, DSM III included a number of major advances and redefinition of various mental disorders which we'll be discussing shortly.

3. Clinical Diagnosis 3 Criticisms of Psychiatric Diagnoses Confusing categorization with explanation Problem with clinical consensus Concerns about reliability and validity Reinforces the medical model view of psychopathology

4. Clinical Diagnosis 4 Objectives of the Current Diagnostic System Enhance diagnosis Facilitate agreement among clinicians Enhance communication among clinical researchers

5. Clinical Diagnosis 5 Definition of a Mental Disorder �A clinically significant behavioral or psychological syndrome or pattern that occurs in a person and that is associated with present distress or disability or with a significantly increased risk of suffering death, pain, disability, or an important loss of freedom.�

6. Clinical Diagnosis 6 Definitional Features The syndrome must not be merely an expected response to an event The syndrome must not be merely deviant behavior or conflicts between the person and society Does not assume a discontinuity between each mental disorder

7. Clinical Diagnosis 7 Definitional Features Classifies mental disorders not people Does not assume that people with a mental disorder are alike in all ways

8. Clinical Diagnosis 8 Basic Features of DSM-IV Uses a descriptive (as opposed to theoretical) approach to diagnosis

9. Clinical Diagnosis 9 Descriptive Breakdown Clinical features associated with the disorder Specific predisposing factors Differential diagnostic considerations Typical onset, clinical course, impairment, and complications Specific diagnostic criteria

10. Clinical Diagnosis 10 Basic Features of DSM-IV Uses a descriptive approach to diagnosis Uses specific criteria for each disorder

11. Clinical Diagnosis 11 Example of Diagnostic Criteria A. Preoccupation with fears of having, or the idea that one has, a serious disease based on the person�s misinterpretation of bodily symptoms B. The preoccupation persists despite appropriate medical evaluation and reassurance C. The belief in A is not of delusional intensity and is not restricted to a circumscribed concern about appearance D. The preoccupation causes clinically significant distress or impairment in social, or occupational functioning E. The duration of disturbance is at least 6 months F. The preoccupation is not better accounted for by another disorder

12. Clinical Diagnosis 12 Basic Features of DSM-IV Uses a descriptive approach to diagnosis Uses specific criteria for each disorder Uses a polythetic approach to diagnostic criteria

13. Clinical Diagnosis 13 Example of Polythetic Approach DSM-IV Diagnostic Criteria for a Panic Attack (P 395). A discrete period of intense fear or discomfort, in which 4 or more of the following symptoms developed abruptly and reached a peak within 10 minutes: Palpitations, pounding heart, accelerated heart rate Sweating Trembling or shaking Sensations of shortness of breath or smothering Feeling of choking Chest pain or discomfort Nausea or abdominal distress Feeling dizzy, unsteady, lightheaded, or faint derealization or depersonalization Chills or hot flushes Numbness or tingling sensations Fear of losing control or going crazy Fear of dying

14. Clinical Diagnosis 14 Basic Features of DSM-IV Uses a descriptive approach to diagnosis Uses specific criteria for each disorder Uses a polythetic approach to diagnostic criteria Uses some hierarchical organization of diagnostic classes

15. Clinical Diagnosis 15 Examples of Hierarchical Organization Person who displays mood disturbance in the context of a dementia or other brain disease is not also given a mood disorder diagnosis Person who displays anxiety disturbance in the presence of paranoid schizophrenia is not also given an anxiety disorder diagnosis Person who displays gross disturbance in personality in the context of a brain disorder (cognitive disorder) or schizophrenia is not also given a personality disorder diagnosis

16. Clinical Diagnosis 16 Basic Features of DSM-IV Uses a descriptive approach to diagnosis Uses specific criteria for each disorder Uses a polythetic approach to diagnostic criteria Uses a hierarchical organization of diagnostic classes Uses a Multiaxial system of classification

17. Clinical Diagnosis 17 Multiaxial Classification Axis I - Clinical syndromes

18. Clinical Diagnosis 18 Clinical Syndromes Disorders Usually first diagnosed in infancy, childhood, or adolescence Delirium, dementia, amnestic, and other cognitive disorders Substance-related disorders Schizophrenia and other psychotic disorders Mood disorders Anxiety disorders Somatoform disorders Factitious Disorders Dissociative disorders Sexual and gender identity disorders Eating disorders Sleep disorders Impulse control disorders Adjustment disorders

19. Clinical Diagnosis 19 Multiaxial Classification Axis I - Clinical syndromes Axis II - Personality disorders and specific developmental disorders

20. Clinical Diagnosis 20 AXIS II: Personality DisordersMental Retardation Paranoid personality disorder Schizoid personality disorder Schizotypal personality disorder Antisocial personality disorder Borderline personality disorder Histrionic personality disorder Narcissistic personality disorder Avoidant personality disorder Dependent personality disorder Obsessive-compulsive personality disorder Personality disorder not otherwise specified Mental retardation

21. Clinical Diagnosis 21 Multiaxial Classification Axis I - Clinical syndromes Axis II - Personality disorders and specific developmental disorders Axis III - Physical disorders and conditions

22. Clinical Diagnosis 22 AXIS III: General Medical Conditions Infectious and parasitic diseases Neoplasms Endocrine, nutritional, metabolic, and immunity diseases Diseases of the nervous system Diseases of the circulatory system Diseases of the respiratory system Diseases of the digestive system Diseases of the genitourinary system Diseases of the skin Diseases of the musculoskeletal system Injury and poisoning Complications of pregnancy and childbirth

23. Clinical Diagnosis 23 Multiaxial Classification Axis I - Clinical syndromes Axis II - Personality disorders and specific developmental disorders Axis III - Physical disorders and conditions Axis IV - Psychosocial stressors

24. Clinical Diagnosis 24 AXIS IV: Psychosocial Stressors Problems with primary support group e.g., death of a family member Problems related to the social environment e.g., loss of a friend, retirement Educational problems e.g., academic problems Occupational problems e.g., unemployment Housing problems e.g., homelessness Economic problems e.g., extreme poverty, inadequate finances Problems with access to health care services Problems with legal system e.g., arrest, victim of crime

25. Clinical Diagnosis 25 Multiaxial Classification Axis I - Clinical syndromes Axis II - Personality disorders and specific developmental disorders Axis III - Physical disorders and conditions Axis IV - Psychosocial stressors Axis V - Global assessment of functioning

26. Clinical Diagnosis 26 AXIS V: Global Assessment of Functioning (GAF) 91-100 � Superior functioning in a wide range of areas (e.g., social, academic, occupational, etc.) 81-90 � Absent or minimal symptoms 71-80 � If symptoms are present they are transient and expected reactions to psychosocial stressors 61-70 � Mild symptoms or some difficulty in functioning 51-60 � Moderate symptoms or moderate difficulties in functioning 41-50 � Serious symptoms or any serious difficulties in functioning 31-40 � Some impairment in reality testing or communication or serious difficulties in functioning in several areas of functioning 21-30 � Behavior is considerably influenced by delusions or hallucinations or serious impairment in communication or judgment 11-20 � Some danger of hurting self or others 0-10 � Persistent danger of hurting self or others or persistent inability to maintain minimal personal hygiene

27. Clinical Diagnosis 27 Examples of Multiaxial Diagnosis Axis I: 296.23 Major depression, single episode, severe without psychotic features300.90 alcohol dependence Axis II: 301.60 Dependent Personality Disorder Axis III: Alcoholic cirrhosis of liver Axis IV: Psychosocial stressors: anticipated retirement and loss of friendsSeverity: 4 - Moderate Axis V: Current GAF: 44Highest GAF past year: 55

28. Clinical Diagnosis 28 Examples of Multiaxial Diagnosis Axis I: 309.24 Adjustment Disorder with Anxious Mood Axis II: V71.09 No diagnosis on Axis II Axis III: None Axis IV: Psychosocial stressors: Change of schoolSeverity: 2 - Mild Axis V: Current GAF: 70Highest GAF past year: 85

29. Clinical Diagnosis 29 Examples of Multiaxial Diagnosis Axis I: 295.94 Schizophrenia, Undifferentiated Type Axis II: V 71.09 No diagnosis on Axis II Axis III: Late effects of viral encephalitis Axis IV: Psychosocial stressors: death of motherSeverity: 6 - Extreme Axis V: Current GAF: 28Highest GAF past year: 40

30. Clinical Diagnosis 30 Empirical Dimensional Approach to Classification �Quantitative taxonomy� (Compas & Gotlib text, pp. 126-129) Achenbach�s �Child Behavior Checklist� (�Internalizing� and �Externalizing� dimensions) Krueger�s (1999) National Comorbidity Survey (N = 8,098), revealing similar empirically derived factors for adult mental disorders