DSM Overview of DSM Lecture Brief history Brief overview How to use it Differentials & R/Os malingering, factitious dis, meds/medical, substance, organic Co-morbidity/dual-diagnosis Substance Use/Abuse Linking diagnosing to treatment 1 2 DSM Multiaxial system assumes a disease model and assigns labels to behaviors often described as being atheoretical is it? has a formal classification scheme for behaviors which can be useful organizes people into categories negative side is that information about an individual is lost the DSM is a multiaxial system - there are five different axes Axis I - clinical syndromes the presenting problem of the person Axis II - developmental or personality variables - long term problems that interfere with functioning Axis III - physical disorders - related to what's going on currently 3 4 Multiaxial system Axis I Axis IV and V cover context variables Don t forget to assess these! Axis IV - Psychosocial stressors related to the environment an outside stress is generally a positive sign Why? Axis V - Global assessment of functioning current functioning and highest in past year various disorders or conditions noting Other Conditions That May Be A Focus Of Clinical Attention 14 categories Each are coded with number and with name (have to at least have the name) Specifiers Need to know these May be useful or predictive 5 6 1
Axis I Axis II Anxiety Dis, Childhood Disorders, Cognitive Dis, Dissociative Dis, Eating Dis, Factitious Dis, Impulse Control Dis, Mood Dis, Psychotic Dis, Sexual and Gender Identity Dis, Sleep Dis, Somatoform Dis, and Substance-Related Dis Other conditions Adjustment Disorders V-codes Personality disorders Developmental disorders Long-standing, pervasive repertoire deficits Each are coded with number and with name (have to at least have the name) 7 8 Axis III General Medical Conditions current medical conditions potentially relevant to understanding or management of problems purpose to encourage thoroughness in evaluation and to enhance communication among health care providers write down the name of the problems(s) Axis III related to mental disorders in variety of ways if clear medical condition directly relates to the development or worsening of the problem the relationship between the medical condition and problem symptoms is not understood yet there are situations the medical condition is important to understanding or treatment of the problem 9 10 Axis IV Psychosocial Stressors Write down the name of the problem area(s) and the specific problem person has may affect diagnosis treatment prognosis Axis IV may be a negative life event an environmental difficulty or deficiency a familial or other interpersonal stress an inadequacy of social support or personal resources other problem relating to the context problems occur Positive stressors (e.g., a job promotion) only listed if constitute or lead to a problem 11 12 2
Axis V Axis V Global Assessment of Functioning Two assessments give (ALWAYS) Current level of functioning AND The highest level of functioning in the past year can potentially have some predictive value want to know what best hopes of recovery are given the person s optimal functioning in the last year Estimates are fine, but need to be within 5 points Funding can be affected by these scores 13 14 Axis V An example of the DSM in action In general: 0 = Not enough information 70 and up doing fine (understandable stress levels) to great 70-61 mild 60-51 Moderate 50-41 Severe 40-11 Very bad 1-10 Near dead Ax 1 Major Depressive Episode, Severe, Recurrent; Alcohol Dependence, in partial sustained remission Ax 2 - Dependent Personality Disorder Ax 3 - Diabetes Mellitus, type 2 Ax 4 - Psychosocial stressors recent job loss, problems with access to health care Ax 5 - current GAF - 45; Highest GAF past year- 65 15 16 Differentials & Rule Outs Differentials & Rule Outs Some terminology Differential Diagnosis List of other disorders which may cause or show the same symptoms or behaviors To make a differential you are saying why your diagnosis is not (is differentiated from) another disorder When you make this differential you say that you have ruled out (abbreviate as R/O) a disorder Differential Diagnosis If you need more information to determine the diagnosis or differentiate it from others, you say that you need to rule out [other diagnosis] Differentials then are Disorders to be ruled out Disorders that are ruled out already 17 18 3
R/Os & Differentials Differential Diagnoses somatoform hypochondriasis factitious disorders malingering organic damage meds/medical issues (general medical condition) substance adjustment disorders Very, very important to know differentials Many inaccurate diagnoses Very different treatment courses for some disorders e.g. BAD vs BPD Don t need to treat a problem that will naturally resolve Don t treat a medical problem with a psychological treatment 19 20 Somatoform Disorders General: Problems that suggest a general medical condition but can t be explained by a medical condition Need for treatment: recent full physical exam consent to get medical records consent to talk to doctor Somatoform Disorders May need to make treatment contingent on medical exam Need to know cultural issues that predispose to a mind set about illness, pre-occupation with illness, or need to express psychological distress somatically 21 22 Somatization Disorder Pain Disorder History of many physical complaints beginning before age 30 years that occur over a period of several years and result in treatment being sought or significant impairment in social, occupational, or other important areas of functioning Each of the following criteria must have been met, with individual symptoms occurring at any time during the course of the disturbance: four pain symptoms, two gastrointestinal symptoms, one sexual symptom, one pseudoneurological symptom Pain in one or more anatomical sites is the predominant focus of the clinical presentation and is of sufficient severity to warrant clinical attention The pain causes clinically significant distress or impairment in social, occupational, or other important areas of functioning. 23 24 4
Pain Disorder Hypochondriasis (300.7) Psychological factors are judged to have an important role in the onset, severity, exacerbation, or maintenance of the pain. The symptom or deficit is not intentionally produced or feigned (as in Factitious Disorder or Malingering) The pain is not better accounted for by a Mood, Anxiety, or Psychotic Disorder and does not meet criteria for Dyspareunia (genital pain associated with sexual intercourse) Somatoform Disorder Preoccupation with fears of having, or the idea that one has, a serious disease based on the person's misinterpretation of bodily symptoms The preoccupation persists despite appropriate medical evaluation and reassurance 25 26 Hypochondriasis Hypochondriasis The belief is not of delusional intensity (as in Delusional Disorder, Somatic Type) and is not restricted to a circumscribed concern about appearance (as in Body Dysmorphic Disorder) The preoccupation causes clinically significant distress or impairment in social, occupational, or other important areas of functioning The duration of the disturbance is at least 6 months The preoccupation is not better accounted for by Generalized Anxiety Disorder, Obsessive- Compulsive Disorder, Panic Disorder, a Major Depressive Episode, Separation Anxiety, or another Somatoform Disorder Specifier: With Poor Insight (no recognition of how unreasonable this is) 27 28 Factitious Disorder (300.16,.19) Malingering (V65.2) Intentional production or feigning of physical or psychological signs or symptoms motivation is to be in sick role external incentives (economic, legal) are absent aka Munchausen s Syndrome/Disease/Disorder Also see FD By Proxy aka Munchausen Syndrome By Proxy Intentional production of false or grossly exaggerated physical or psychological symptoms Motivated by external incentives (e.g., legal, avoid job/role, economic, getting drugs) Watch for with ASPD 29 30 5
Psychological Factors and Physical Disorders No real physical findings physical findings complicated by Psychological factors Other Common Differentials external gain Malingering Intentional feigning internal gain Factitious Disorder -physical -psychological -by proxy no awareness of symptom production Somatoform disorders Hysterical disorders somatization disorder conversion disorder pain disorder preoccupation disorders hypochondriasis body dysmorphic disorder Psychological Factors affecting medical condition Organically produced behavioral anomalies or syndromes organic damage dementias Medical issues (disorder due to general medical condition) variety of medical problems thyroid problems 31 32 Other Differentials Medications look for medication side effects may be produced by the drug taken to alleviate the problem Substance abuse many drugs produce psychological profiles Need to rule these out as being the causes of the behavior May also be co-morbid Co-morbidity/dual-diagnosis Many disorders are co-morbid Most often with substance use Substance Abuse Substance Dependence Need to dually diagnose with current system 33 34 Substance Dependence Continued use of drug despite the negative consequences (physiological or psychological) in order to avoid the aversive effects of not taking the substance Note that this has specific connotations Negative consequences Do not say that someone is insulin-dependent pejoratively Adjustment Disorder Significant life events, whether positive or negative, can stress us emotionally and psychologically. The resulting presence of symptoms and impaired functioning can result in a diagnosis of one of the mental disorders we call an adjustment disorder. These can be further classified as adjustment disorder with (Depressed Mood, Anxiety, Disturbance of Conduct, Mixed Anxiety and Depressed Mood, Mixed Disturbance of Emotions and Conduct) 35 36 6
Using Differentials Using Differentials Need to use these thoughtfully Need top 3 or 4 REAL differentials This is based on a thoughtful conceptualization of the case NOT the case that organic, general medical condition, and substance are the three rule outs for everything Ask the following for differentials What does this disorder resemble? Why would I need to differentiate this set of problems from those? Always provide clear rationale and justification It isn t [X disorder] because It would be important to rule out [X disorder] because 37 38 Criticisms of DSM Linking Diagnosing to Treatment too many people have disorders not specific enough (Catchment study) half of people who seek treatment can t be labeled using current system reliability and validity is a problem DSM system is not functional - does not guide/tell therapists how to treat clients Need to assess around problems While you do this, you can determine for what diagnosis(es) person meets criteria These are done as separate acts End up only diagnosing Do not do this You assessment is for the client The diagnosis is a product of the assessment 39 40 The Link to Treatment Ask these questions Make sure you ask the who, when, where, and how Be careful with the why s Try to use the DSM groups of problems to guide your assessment of YOUR client Let these syndromes help guide your assessment What is going on for THIS client? What are the variables that affect THIS client that produce THIS behavioral problem? What are the contextual cues for THIS client that must be taken into account? When do these problems occur? 41 42 7
Ask these questions What makes the problems better? What makes the problems worse? How could a change in circumstances produce a change for the person? How can I fit these problems into a diagnostic category? 43 8