Diagnosis in the Assessment Process

“….making diagnoses and using them in treatment planning has become an integral part of what all mental health

professionals do” (Neukrug & Fawcett, 2010, p. 245).

The Importance of a Diagnosis

1. Federal & state laws require that students with severe emotional disorders be serviced in the schools. Diagnosis helps to identify the specific mental disorder with which a student may be struggling and can be useful in deciding treatment strategies.

2. A mental disorder diagnosis is usually required if medical insurance is to reimburse for treatment. Insurance companies will sometimes want to monitor progress as a function of the kind of diagnosis made.

The Importance of a Diagnosis

3. Familiarity with the wording of the DSM-IV-TR has become critical to effective communication between clinicians.

4. A definitive diagnosis that points to a biological influence (e.g., genetics, environmental factors such as lead paint) can be critical for the proper treatment of an individual.

The Importance of a Diagnosis

5. Diagnosis has become a critical aspect of the total assessment process and can be helpful in case conceptualization and in treatment planning.

The DSM-IV-TR“Diagnosis refers to the process of making an

assessment of an individual from an outside, or objective, viewpoint” (Neukrug & Fawcett, 2010, p. 147).

DSM-IV-TR: Accepted diagnostic classification system for mental disorders developed by the American Psychiatric Association

DSM-IV-TR: Characteristics“The most widespread and accepted

diagnostic classification system of emotional disorders in the world” (Neukrug & Fawcett, 2010, p. 247). Five axes to assist in diagnosis and treatment of

mental disorders Many clinicians will use two or more of the axes The five axes allow clinicians to accurately

describe their clients & communicate details related to the client to other clinicians

DSM-IV-TR: 5 Axes “A diagnosis can help a clinician determine the primary

focus of counseling and assist in deciding which interventions might be most useful” (Neukrug & Fawcett, 2010, p. 247).

1. Axis 1: Clinical disorders and other conditions that may be a focus of clinical attention

2. Axis 2: Delineates personality disorders and mental retardation

3. Axis 3: Explains general medical conditions

4. Axis 4: Describes psychosocial & environmental problems

5. Axis 5: Offers a global assessment of functioning

DSM-IV-TR: Usefulness

“Although all five axes can be helpful in determining the kind of intervention and in treatment planning, the first two axes focus specifically on helping the clinician determine what kind of disorder an individual may be displaying” (Neukrug & Fawcett, 2010, p. 247).

DSM-IV-TR: Axes 1 & 2: Highlights

1. Each disorder listing describes:

a) The disorder’s main features

b) Subtypes and variations in client

presentations

c) The typical pattern, course, or progression

of symptoms

d) How to differentiate the disorder from other,

similar ones

DSM-IV-TR: Axes 1 & 2: Highlights

2. Provides findings about predisposing factors, complications, and associated medical & counseling problems - when they are known

3. Does not hypothesize about etiology of a disorder when information is not known

4. Diagnoses are intended to be theory-neutral descriptions of behavior, thoughts, mood, physiology, functioning, and distress.

DSM-IV-TR: Axis 1 & 2: Highlights

4. Continued: Because DSM-IV-TR categories and descriptors are designed to be theory-neutral, clinicians are able to apply their own theoretical orientation to the treatment planning process

5. DSM-IV-TR offers a decision tree that helps in distinguishing similar diagnoses from one another

DSM-IV-TR: Axis 1 & 2: Misconceptions

Myth: Clinicians must view all client concerns from a very clinical, psychopathological viewpoint.

Fact: DSM-IV-TR is used to share information about a subset of human experience - those conditions that meet the “mental disorder” definition

DSM-IV-TR: Axis 1 & 2: Cultural Issues & Mental Disorders:

Criticisms

The DSM has been criticized as not being cross-culturally sensitive Minorities tend to be misdiagnosed at higher

rates than Whites Some argue that the use of a diagnostic

criterion tends to minimize the negative influences that external events have on clients, such as, racism and discrimination.

DSM-IV-TR: Addressing Cross-cultural Fairness

1. Developers made considerable effort to address cross-cultural issues: DSM-IV-TR notes that schizophrenia is

sometimes diagnosed instead of bipolar disorder in non-Whites and younger clients

DSM-IV-TR notes that somatic complaints, such as headaches among Latinos and fatigue and weakness among Asians, are symptoms that could be representative of depression more frequently in these cultural groups than in others

DSM-IV-TR: Addressing Cross-cultural Fairness

2. The DSM-IV-TR include an appendix of culture-specific syndromes not included elsewhere Although these syndromes might be problematic in

the client’s culture of origin, in the U.S., these syndromes often get misconstrued or exaggerated by an uninformed counselor, i.e., nervios: Common stress disorder among Latinos. Symptoms include emotional distress, nervousness, tearfulness, and bodily complaints

DSM-IV-TR: Addressing Cross-cultural Fairness

3. The DSM-IV-TR addresses expected reactions/culturally appropriate responses to life events: Suggests that these are usually not diagnosable

as mental disorders, even though they may cause the client distress

• Examples include: – Loss of a loved one

– Expected developmental experiences (adolescence)

DSM-IV-TR:Addressing Cross-cultural Fairness

4. DSM-IV-TR pays greater attention to differences in symptom expression as a function of age, gender, socioeconomic status, and culture Age: For example, major depression is associated

with increased withdrawal in children, oversleeping in adolescents, and memory loss in older adults

Gender: For example bipolar disorders are equally common among men & women, but major depression is more common among women. Obsessive-compulsive disorder is more common among men

Axis 1 Disorders

“Axis 1 disorders are considered treatable and often temporary” (Neukrug & Fawcett, 2010, p. 249).

Generally, Axis 1 disorders are often reimbursable by insurance companies

Axis 1 disorders include all disorders except those classified as personality disorders or as mental retardation

Axis 1 Disorders1. Disorders Usually First Diagnosed in Infancy,

Childhood, or Adolescence (may sometimes be diagnosed in adulthood)

Learning disorders Motor skills disorders Communication disorders Pervasive developmental disorders Attention-deficit and disruptive behavior disorders Feeding and eating disorders of infancy or early childhood Tic disorders Elimination disorders Other disorders of infancy, childhood, or adolescence

Axis 1 Disorders2. Delirium, Dementia, Amnestic, and Other Cognitive

Disorders: Represent a significant change from past cognitive functioning of client

Caused by a medical condition or substance (drug abuse, medication, or allergic reaction)

3. Mental Disorders Due to a General Medical Condition: When mental disorder is the result of a medical condition and includes personality changes and mental disorders not otherwise specified

4. Substance-related Disorders: Disorder is a direct result of the use of a drug or alcohol, the effects of medication, or exposure to a toxin

Axis 1 Disorders

5. Schizophrenia and Other Psychotic Disorders: Psychotic symptomatology is the most distinguishing feature.

Schizophrenia Schizophreniform disorder Schizoaffective disorder Delusional disorder Brief psychotic disorder Shared psychotic disorder Psychotic disorder due to a general medical condition Substance-induced psychotic disorder Psychotic disorder not otherwise specified

Axis 1 Disorders

6. Mood Disorders: Mood disturbances of the depressive, manic, or hypomanic type. Include 5 broad categories:

• Depressive disorders

• Bipolar disorders

• Mood disorder due to a general medical condition

• Substance-induced mood disorder

• Mood disorder not otherwise specified

Axis 1 Disorders7. Anxiety Disorders: There are many distinct types of

anxiety disorders, each with its own unique characteristics:

Panic disorder with or without agoraphobia Agoraphobia without history of panic disorder Specific phobia Obsessive-compulsive disorder Posttraumatic stress disorder Acute stress disorder Generalized anxiety disorder Anxiety disorder due to a general medical condition Substance-induced anxiety disorder Anxiety disorder not otherwise specified

Axis 1 Disorders8. Somatoform Disorders: Characterized by symptoms

that would suggest a physical cause; however, no such cause can be found. Strong evidence exists that link symptoms to psychological causes:

Somatization disorder Undifferentiated somatoform disorder Conversion disorder Pain disorder Hypochondriasis Body dysmorphic disorder Somatoform disorder not otherwise specified

Axis 1 Disorders

9. Factitious Disorders: Intentionally feigned physical or psychological symptoms for the purpose of assuming a sick role: Two subtypes:

• Factitious disorder w/predominantly psychological signs and symptoms

• Factitious disorder w/predominantly physical signs and symptoms

Axis 1 Disorders

10. Dissociative Disorders: Occur when there is a disruption of consciousness, memory, identity, or perception of the environment:

Dissociative amnesia Dissociative fugue Dissociative identity disorder (formerly called, “multiple

personality disorder”) Depersonalization disorder Dissociative disorder not otherwise specified

Axis 1 Disorders

11. Sexual and Gender Identity Disorders: Disorders that focus on sexual problems or identity issues related to sexual issues:

Sexual dysfunctions Paraphilias Gender identity disorders Sexual disorder not otherwise specified

Axis 1 Disorders

12. Eating Disorders: Focus on severe problems with the amount of food intake by the individual that can potentially cause serious health problems or death:

Anorexia nervosa Bulimia nervosa Eating disorder not otherwise specified

Axis 1 Disorders

13. Sleep Disorders: Severe sleep-related problems: Four subcategories:

• Primary sleep disorders

• Sleep disorder related to another mental condition

• Sleep disorder due to a general medical condition

• Substance-induced sleep disorder

Axis 1 Disorders

14. Impulse Control Disorders Not Elsewhere Classified: Highlighted by the individual’s inability to stop himself or herself from exhibiting certain behaviors:

Intermittent explosive disorder Kleptomania Pyromania Pathological gambling Trichotillomania Impulse-control disorder not otherwise specified

Axis 1 Disorders15. Adjustment Disorders: Highlighted by emotional or

behavioral symptoms that arise in response to psychosocial stressors.

Probably the most common disorders clinicians see Subtypes include:

• Adjustment disorders w/depressed mood

• Adjustment disorders w/anxiety

• Adjustment disorders w/mixed anxiety & depressed mood

• Adjustment disorders w/disturbance of conduct

• Adjustment disorders w/mixed disturbance of emotions & conduct

• Unspecified adjustment disorder

Axis II Disorders:Personality Disorders & Mental Retardation

“Axis II disorders tend to be lifelong and resistant to treatment” (Neukrug &Fawcett, 2010, p. 251).

Treatment tends to have little or no effect

Two types of Axis II Disorders: Mental retardation Personality disorders

Axis II Disorders:Mental Retardation

Mental retardation is characterized by intellectual functioning significantly below average (below 2nd percentile) and includes problems with adaptive skills (daily living skills) Four categories of mental retardation:

• Mild mental retardation (IQ of 50-55 to approximately 70)

• Moderate mental retardation (IQ of 35-40 to 50-55)

• Severe mental retardation (IQ of 20-25 to 35-40)

• Profound mental retardation (IQ below 20 or 25)

Axis II Disorders:Personality Disorders

Individuals with personality disorders will show deeply ingrained, inflexible, and enduring patterns of relating to the world that lead to distress and impairment in functioning. May have difficulty understanding self & others May be emotionally labile (changeable) May have difficulty in relationships May have problems with impulse control Generally, first recognized during adolescence or

early adulthood - & may remain throughout lifetime

Axis II Disorders:Personality Disorders

Three clusters of personality disorders: Each cluster represents a general way of relating to the world

• Cluster A: Includes paranoid, schizoid, and schizotypal personality disorders. Individuals exhibit characteristics that may be considered odd or eccentric by others.

• Cluster B: Include the antisocial, borderline, histrionic, and narcissistic personality disorders. Individuals are generally dramatic, emotional, overly sensitive, and erratic.

• Cluster C: Includes the avoidant, dependent, and obsessive-compulsive personality disorders. Individuals show anxious and fearful traits.

Axis III Disorders: General Medical Conditions

Axis III provides the clinician the opportunity to report relevant medical conditions of the client. If a medical condition is related to the cause (or

worsening) of a mental disorder, then the medical condition is noted on Axis I & listed on Axis III.

If a medical condition is not a cause of the mental disorder but will affect overall treatment of the individual, then it is listed only on Axis III..

• The International Classification of Diseases, 9th revision, is used to code the Axis III medical condition

Axis IV Disorders:

Psychosocial & Environmental Problems Psychosocial or environmental problems that affect the

diagnosis, treatment, & prognosis of mental disorders listed on Axis I & II.

Generally, problems will be listed only on Axis IV When it is believed that such stressors may be a prime cause

of the mental disorder, a reference should be made to them on Axis I or II

Problems include problems with one’s primary support group, problems related to the social environment, educational problems, occupational problems, housing problems, economic problems, problems with access to health care services, problems related to interaction with the legal system (crime)

Axis V Disorders: Global Assessment of Functioning (GAF)

Axis V is a scale used by clinicians to assess a client’s overall functioning and is based on an assessment of the client’s psychological, social, and occupational functioning.

GAF scale ranges from very severe dysfunction to superior functioning (Numeric scale ranging from 1-100)

A score of zero means there is inadequate information to make a judgment

A clinician can report current functioning, the highest functioning within the past year, or any other relevant GAF ratings based on the uniqueness of the situation

Making a Diagnosis“Making an appropriate diagnosis is critically important

because the diagnosis will affect treatment planning and choices of psychotropic medication” (Neukrug & Fawcett, 2010, p. 255).

DSM-IV-TR offers decision trees to assist the clinician in differential diagnosis

If two or more diagnoses are being considered that share similar symptoms, the decision tree walks the clinician through a series of steps designed to assist in choosing the most appropriate diagnosis

It is possible for a client to have more than one Axis I and Axis II diagnoses (multiaxial). All diagnoses should be reported.

The DSM-IV-TR:One Piece of the Assessment Process

“Along with the clinical interview, the use of tests, and informal assessment procedures,” the DSM-IV-TR can add essential information to the overall assessment process (Neukrug & Fawcett, 2010, p. 255).

Scenario Time:Applying Textbook Knowledge to Real World Situations:)

Joshua

Facts in the case: Joshua is 10-years-old He is an only child Parents have been married for 6 years Parents have commented that Joshua has been a difficult child

since birth Parents report that he has difficulty in school and didn’t read

until 4th grade• Reading scores low & teacher has suggested having him tested for a

possible reading learning disability No obvious physical problems have been found to cause his

deficiency in reading

Scenario Time:

Applying Textbook Knowledge to Real World Situations:) Joshua, Cont’d.

Additional Facts: Joshua cries easily and often “has a fit” when he has to leave home to go to

school Plagued by nightmares, often revolving around issues of being alone or

separated from his parents Has frequent stomach aches and has vomited at school on numerous

occasions His anxiety and reading problems have interfered with his ability to build

friendships, and he has no close friends and few peers he relates to at school

His parents (who are college educated) are worried that their son will not make it through high school & are concerned about his social relationships

Global Assessment of Functioning Scale (GAF)For those 18 years of age and older

91-100 Superior functioning in a wide rage of activities, life's problems never seem to get out of hand, is sought out by others because of his or her many qualities. No symptoms.

90-81 Absent or minimal symptoms, good functioning in all areas, interested and involved in a wide range or activities, socially effective, generally satisfied with life, no more than everyday problems or concerns.

80-71 If symptoms are present they are transient and expectable reactions to psychosocial stresses; no more than slight impairment in social, occupational, or school functioning

70-61 Some mild symptoms OR some difficulty in social, occupational, or school functioning, but generally functioning pretty well, has some meaningful interpersonal relationships.

60-51 Moderate symptoms OR any moderate difficulty in social, occupational, or school functioning.

50-41 Serious symptoms OR any serious impairment in social, occupational, or school functioning.

40-31 Some impairment in reality testing or communication OR major impairment in several areas, such as work or school, family relations, judgment, thinking, or mood.

30-21 Behavior is considered influenced by delusions or hallucinations OR serious impairment in communications or judgment OR inability to function in all areas.

20-11 Some danger or hurting self or others OR occasionally fails to maintain minimal personal hygiene OR gross impairment in communication.

10-1 Persistent danger of severely hurting self or others OR persistent inability to maintain minimum personal hygiene OR serious suicidal act with clear expectation of death.

Children’s Global Assessment of Functioning Scale: Ages 6-17100-91 Superior functioning in all areas (at home, at school and with peers); involved in a wide range of activities and has many interests

(e.g., has hobbies or participates in extracurricular activities or belongs to an organized group such as Scouts, etc); likeable, confident; ‘everyday’ worries never get out of hand; doing well in school; no symptoms.

90-81 Good functioning in all areas; secure in family, school, and with peers; there may be transient difficulties and ‘everyday’ worries that occasionally get out of hand (e.g., mild anxiety associated with an important exam, occasional ‘blowups’ with siblings, parents or peers).

80-71 No more than slight impairments in functioning at home, at school, or with peers; some disturbance of behavior or emotional distress may be present in response to life stresses (e.g., parental separations, deaths, birth of a sibling), but these are brief and interference with functioning is transient; such children are only minimally disturbing to others and are not considered deviant by those who know them.

70-61 Some difficulty in a single area but generally functioning pretty well (e.g., sporadic or isolated antisocial acts, such as occasionally playing hooky or petty theft; consistent minor difficulties with school work; mood changes of brief duration; fears and anxieties which do not lead to gross avoidance behavior; self-doubts); has some meaningful interpersonal relationships; most people who do not know the child well would not consider him/her deviant but those who do know him/her well might express concern.

60-51 Variable functioning with sporadic difficulties or symptoms in several but not all social areas; disturbance would be apparent to those who encounter the child in a dysfunctional setting or time but not to those who see the child in other settings.

50-41 Moderate degree of interference in functioning in most social areas or severe impairment of functioning in one area, such as might result from, for example, suicidal preoccupations and ruminations, school refusal and other forms of anxiety, obsessive rituals, major conversion symptoms, frequent anxiety attacks, poor to inappropriate social skills, frequent episodes of aggressive or other antisocial behavior with some preservation of meaningful social relationships.

40-31 Major impairment of functioning in several areas and unable to function in one of these areas (i.e., disturbed at home, at school, with peers, or in society at large, e.g., persistent aggression without clear instigation; markedly withdrawn and isolated behavior due to either mood or thought disturbance, suicidal attempts with clear lethal intent; such children are likely to require special schooling and/or hospitalization or withdrawal from school (but this is not a sufficient criterion for inclusion in this category).

30-21 Unable to function in almost all areas e.g., stays at home, in ward, or in bed all day without taking part in social activities or severe impairment in reality testing or serious impairment in communication (e.g., sometimes incoherent or inappropriate).

20-11 Needs considerable supervision to prevent hurting others or self (e.g., frequently violent, repeated suicide attempts) or to maintain personal hygiene or gross impairment in all forms of communication, e.g., severe abnormalities in verbal and gestural communication, marked social aloofness, stupor, etc.

10-1 Needs constant supervision (24-hour care) due to severely aggressive or self-destructive behavior or gross

impairment in reality testing, communication, cognition, affect or personal hygiene.

Children’s Global Assessment of Functioning

See:http://depts.washington.edu/washinst/Resources/CGAS/CGAS%20Index.htm

DSM-IV-TR: Joshua’s Assessment Outcome

Joshua

Axis I: ____________

____________

Axis II:____________

Axis III: ____________

Axis IV: ____________

Axis V: ____________

DSM-IV-TR: Joshua’s Assessment Outcome

Joshua

Axis I: Rule Out Reading Disorder

Separation Anxiety Disorder

Axis II:None

Axis III: Stomach Aches

Axis IV: Problems relating to peers at school

Axis V: GAF = 61 (Current)