survey of modern psychology

Survey of Modern Psychology

Diagnosis and the DSM-IV-TR

The DSM-IV-TR

Diagnostic and Statistical Manual of Mental Disorders

Fourth EditionText Revision

Mental Illness as Defined by the DSM

“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. In addition, this syndrome or pattern must not be merely an expectable and culturally sanctioned response to a particular event, for example, the death of a loved one. Whatever its original cause, it must currently be considered a manifestation of a behavioral, psychological, or biological dysfunction in the individual. Neither deviant behavior (e.g., political, religious, or sexual) nor conflicts that are primarily between the individual and society are mental disorders unless the deviance or conflict is a symptom of a dysfunction in the individual, as described above”

The History of the DSM• Classification of mental illness began in the US in

the 1840s• It was used for collecting statistical information• The first volume only contained the category of

“idiocy/insanity”– In the 1880s, there were 7 categories of mental illness

1.Mania2.Melancholia3.Monomania4.Paresis5.Dementia6.Dipsomania7.Epilepsy

The History of the DSM

• Other early classification of mental illness was “Psychotic” vs. “Neurotic”– Psychotic meant a loss of reality– Neurotic meant any other mental health

symptoms that did not involve (consistent) loss of reality


• In 1917, a new system was created– It was primarily for statistical classification, but

began to have some clinical uses• In the 1940s, the US army started to develop a

nomenclature to describe symptoms of WWII servicemen and veterans– The World Health Organization published the sixth

ICD (“International Classification of Diseases”) and began including mental illness


• In 1952, the first DSM was published– It contained a glossary of descriptions of

diagnostic categories– Was the first official manual of mental disorders

to focus on clinical uses• The second DSM contained more explicit

definitions, needed for reliable diagnosis, but was not hugely different from the first DSM


• The DSM-III was published in 1980• New additions were:– Explicit diagnostic criteria– Multiaxial system– Neutral theoretical approach– Based on empirical work/research

• One of the goals was a medical nomenclature for clinicians and researchers

The DSM-III-R was published in 1987, due to inconsistencies and unclear criteria lists


• Homosexuality originally appeared as a mental illness in the DSM– In the early 1970s, homosexuality in and of itself

was taken out of the DSM– A new diagnosis of “sexual orientation

disturbance” was added, which referred to people who believed that they were homosexual but were upset by it and wanted to change

Perceptions of what constitutes a mental illness can change over time based on changes in

research and public perception


• The DSM-IV was published in 1994• It used a three stage empirical process:

1. Comprehensive and systematic reviews of the published literature

2. Reanalysis of already collected data sets to determine if criteria sets needed changes

3. Extensive field trials relating diagnosis to clinical practice

• New diagnoses were added when necessary– This was only done if research showed they needed

to be added; there is a section of “other conditions that may be a focus of clinical attention”


• The DSM-IV-TR was published in 2000• Incorporates new research, particularly

regarding course, prevalence, familial, and demographic patterns

DSM Criteria

• Every diagnosis lists multiple criteria that must be met for a diagnosis– Some level of clinical judgment should be used,

particularly in cases where a client falls slightly short of a single criterion

– There is a high level of agreement among clinicians and researchers regarding the criteria

• A diagnosis is made based on the individual's current state

DSM Criteria – SpecifiersSeverity• Severity describes the disorder when full criteria

are currently met– Mild: few, if any, symptoms in excess of those required to

make the diagnosis are present, and symptoms result in no more than minor impairment in social or occupational functioning

– Moderate: symptoms or functional impairment between “mild” and “severe” are present

– Severe: many symptoms in excess of those required to make the diagnosis, or several symptoms that are particularly severe, are present, or the symptoms result in marked impairment in social or occupational functioning

DSM Criteria – SpecifiersCourse• This refers to a previous diagnosis– In partial remission: The full criteria for the disorder were

previously met, but currently only some of the symptoms or signs of the disorder remain

– Full remission: there are no longer any symptoms or signs of the disorder, but it is still clinically relevant to note the disorder – for example, in an individual with previous episodes of Bipolar Disorder who has been symptom free on lithium for the past 3 years. After a period of time in full remission, the clinician may judge the individual to be recovered and, therefore, would no longer code the disorder as a current diagnosis.

DSM Criteria – Specifiers Course

– The differentiation of In Full Remission from recovered requires consideration of many factors, including the characteristic course of the disorder, the length of time since the last period of disturbance, the total duration of the disturbance, and the need for continued evaluation or prophylactic treatment

– Prior history: for some purposes, it may be useful to note a history of the criteria having been met for a disorder even when the individual is considered to be recovered from it. Such past diagnosis of mental disorder would be indicated in Prior History (e.g., Separation Anxiety Disorder, Prior History, for an individual with a history of Separation Anxiety Disorder who has no current disorder or who currently meets criteria for Panic Disorder

DSM Criteria – Specifiers

• Provisional Diagnosis– May be used if there is a strong presumption that

the full criteria will be met but there is not enough information available (i.e., the individual cannot give a full history)

– Diagnosis or differential diagnosis is dependent on length of time


• Recurrence – If symptoms occur after the individual has been in

remission, the diagnosis may be made without all criteria being met (i.e., meeting criteria for a Major Depressive Episode for 10 days instead of the usually required 14)

DSM Criteria – SpecifiersNot Otherwise Specified

There are four instances when “not otherwise specified” (NOS) would be used:

1. The presentation conforms to the general guidelines for a mental disorder in the diagnostic class, but the symptomatic picture does not meet the criteria for any of the specific disorders. This would occur either when the symptoms are below the diagnostic threshold for one of the specific disorders or when there is an atypical or mixed presentation


2. The presentation conforms to a symptom pattern that has not been included in the DSM-IV Classification but that causes clinically significant distress or impairment. Research criteria for some of these symptom patterns have been in included in Appendix B


3. There is uncertainty about etiology (i.e., whether the disorder is due to a general medical condition, is substance induced, or is primary)


4. There is insufficient opportunity for complete data collection (e.g., in emergency situations) or inconsistent or contradictory information, but there is enough information to place it within a particular diagnostic class (e.g., the clinician determines that the individual has psychotic symptoms but does not have enough information to diagnose a specific Psychotic Disorder)


• Does not occur exclusively during the course of…– Some disorders may include the symptoms of

another– The second disorder is not diagnosed if it occurs

only while the first diagnosis is present or in partial remission• i.e., a person may only show symptoms of bulimia

during periods of anorexia


• Substance Induced Disorders– The symptoms/disorder are only present when a

substance has been used• i.e., a person who hallucinates only after using marijuana

• General Medical Condition– Some medical conditions can have symptoms

mirroring those of psychiatric disorders– The psychiatric disorder is not diagnosed if the

symptoms disappear upon treatment of the medical condition

Differential Diagnosis

• Some disorders can seem very similar to each other or have overlapping symptoms

• Differential diagnosis decision trees help the clinician rule out various other disorders

Multiaxial Assessment

There are 5 axesI. Clinical Disorders

Other conditions that may be a focus of clinical attention

II. Personality Disorders Mental Retardation

III. General Medical Conditions IV. Psychosocial and Environmental ProblemsV. Global Assessment of Functioning

Multiaxial AssessmentAxis I

• If an individual has more than one clinical disorder, all should be reported on Axis I– The main diagnosis or reason for seeking treatment

should be listed first • If an Axis II diagnosis is the primary reason for seeking

treatment, it should be followed by “principal diagnosis”

• If there is no Axis I diagnosis, it should be coded as V71.09

• If diagnosis is deferred pending additional information, it should be coded as 799.9

Multiaxial AssessmentAxis I

Multiaxial AssessmentAxis II

• May also be used for noting prominent maladaptive personality features or defense mechanisms (that do not qualify as diagnoses)

Multiaxial AssessmentAxis II

Multiaxial AssessmentAxis III

• General medical conditions that are potentially relevant to treating the mental disorder– The medical condition may cause the

psychological condition– The psychological condition may be a reaction to a

medical condition– The medical condition may impact the

pharmacological treatment of the psychological condition

Multiaxial AssessmentAxis IV

• Psychosocial and environmental problems that may affect the diagnosis, treatment, and prognosis of disorders on Axis I or Axis II

• These include:– Problems with 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– Other psychosocial and environmental problems

Multiaxial AssessmentAxis V

• Evaluates the individual’s psychological, social, and occupational functioning– Does not include impairment due to physical or

environmental limitations• The GAF is divided into 10 ranges of functioning and

requires that the clinician pick a single value• Each range has two components in its description:– Symptom severity– Functioning

A lower GAF score is considered “worse”Handout


• The GAF falls into a particular range if either the symptom severity or level of functioning falls into that range– If the severity rating and function ratings are

discordant, the final rating reflects the worse of the two scores• i.e., an individual who is maintaining a social life and

holding a job (low impairment, so high GAF) but is highly suicidal (high severity, low GAF) would have a low final GAF score


1. Starting at the top level, evaluate each range by asking, “is either the individual's symptom severity or level of functioning worse than what is indicated in the range description?”

2. Keep moving down the scale until the range that best matches the individual’s symptom severity or the level of functioning is reached, whichever is worse.


3. Look at the next lower range as a double check against having stopped prematurely. This range should be too severe on both symptom severity and level of functioning. If it is, the appropriate range has been reached (continue with step 4). If not, go back to step 2 and continue moving down the scale

4. To determine the specific GAF rating within the selected 10-point range, consider whether the individual is functioning at the higher or lower end of the 10-point range. For example, consider an individual who hears voices that do not influence his behavior (e.g., someone with long standing Schizophrenia who accepts his hallucinations as part of his illness.) If the voices occur relatively infrequently (once a week or less), a rating of 39 or 40 might be most appropriate. In contrast, if the individual hears voices almost continuously, a rating of 31 or 32 would be more appropriate.

Cons of Diagnosis

• Forces labels on people and may be seen as dehumanizing

• Stigma

Pros of Diagnosis

• Useful in research on mental illness and treatment

• Often necessary on insurance forms• May be less stigmatizing – Conveys the idea that the person is not alone– Diagnosis encourages mental illness to be

acknowledged as real• Easier/more efficient discussion among

members of a treatment team

Mental Illness as Relative

• For symptoms to constitute a disorder, they must result in impairment

• The behavior must also deviate from the norm– A criticism of the diagnosis of Attention

Deficit/Hyperactivity Disorder is that many children are “hyper” and have difficulty sitting still and concentrating in school

Attention Deficit/Hyperactivity Disorder

A. Either (1) or (2): (1)Six (or more) of the following symptoms of

inattention have persisted for at least 6 months to a degree that is maladaptive and inconsistent with developmental level:

Attention Deficit/Hyperactivity DisorderInattentiona) often fails to give close attention to details or makes careless

mistakes in schoolwork, work, or other activitiesb) often has difficulty sustaining attention in tasks or play activitiesc) often does not seem to listen when spoken to directlyd) often does not follow through on instructions and fails to finish

schoolwork, chores, or duties in the workplace (not due to oppositional behavior or failure to understand instructions)

e) often has difficulty organizing tasks and activitiesf) often avoids, dislikes, or is reluctant to engage in tasks that

require sustained mental effort (such as schoolwork or homework)

g) often loses things necessary for tasks or activities (e.g., toys, school assignments, pencils, books, or tools)

h) is often easily distracted by extraneous stimulii) is often forgetful in daily activities


(2) six (or more) of the following symptoms of hyperactivity – impulsivity have persisted for at least 6 months to a degree that is maladaptive and inconsistent with developmental level:

Attention Deficit/Hyperactivity DisorderHyperactivitya) often fidgets with hands or feet or squirms in seatb) often leaves seat in classroom or in other situations in which remaining seated is expectedc) often runs about or climbs excessively in situations in which it is inappropriate (in adolescents or

adults, may be limited to subjective feelings of restlessness)d) often has difficulty playing or engaging in leisure activities quietlye) is often “on the go” or often acts as if “driven by a motor”f) often talks excessivelyImpulsivityg) often blurts out answers before questions have been completedh) often has difficulty awaiting turni) often interrupts or intrudes on others (e.g., butts into conversations or games)


B. Some hyperactive-impulsive or inattentive symptoms that caused impairment were present before age 7 years

C. Some impairment from the symptoms is present in two or more settings (e.g., at school [or work] and at home)

D. There must be clear evidence of clinically significant impairment in social, academic, or occupational functioning

E. The symptoms do not occur exclusively during the course of a Pervasive Developmental Disorder, Schizophrenia, or other Psychotic Disorder and are not better accounted for by another mental disorder (e.g., Mood Disorder, Anxiety Disorder, Dissociative Disorder, or a Personality Disorder)

Conclusions

• The symptoms MUST CAUSE IMPAIRMENT OR DISCOMFORT

• All other possibilities should be examined BEFORE a mental illness is diagnosed

Possible New Additions: Binge Eating Disorder

A. Recurrent episodes of binge eating. An episode of binge eating is characterized by both of the following:

1. eating, in a discrete period of time (e.g., within any 2-hour period), an amount of food that is definitely larger than most people would eat in a similar period of time under similar circumstances

2. a sense of lack of control over eating during the episode (e.g., a feeling that one cannot stop eating or control what or how much one is eating)

Binge Eating DisorderB. The binge-eating episodes are associated with three (or more) of the following:

1. eating much more rapidly than normal 2. eating until feeling uncomfortably full3. eating large amounts of food when not feeling physically hungry4. eating alone because of being embarrassed by how much one is eating5. feeling disgusted with oneself, depressed, or very guilty after overeating

C. Marked distress regarding binge eating is present.D. The binge eating occurs, on average, at least once a week for three months.E. The binge eating is not associated with the recurrent use of inappropriate

compensatory behavior (i.e., purging) and does not occur exclusively during the course of bulimia nervosa or anorexia nervosa.

Hoarding DisorderA. Persistent difficulty discarding or parting with personal

possessions, even those of apparently useless or limited value, due to strong urges to save items, distress, and/or indecision associated with discarding.

B. The symptoms result in the accumulation of a large number of possessions that fill up and clutter the active living areas of the home, workplace, or other personal surroundings and prevent normal use of the space. If all living areas are uncluttered, it is only because of others’ efforts (e.g., family members, authorities) to keep these areas free of possessions

C. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning (including maintaining a safe environment for self and others)

Hoarding DisorderSpecify if: With Excessive Acquisition: If symptoms are accompanied by excessive

collecting or buying or stealing of items that are not needed or for which there is no available space.

Specify whether hoarding beliefs and behaviors are currently characterized by:

Good or fair insight: Recognizes that hoarding-related beliefs and behaviors (pertaining to difficulty discarding items, clutter, or excessive acquisition) are problematic.

Poor insight: Mostly convinced that hoarding-related beliefs and behaviors (pertaining to difficulty discarding items, clutter, or excessive acquisition) are not problematic despite evidence to the contrary.

Delusional: Completely convinced that hoarding-related beliefs and behaviors (pertaining to difficulty discarding items, clutter, or excessive acquisition) are not problematic despite evidence to the contrary.

Non-Suicidal Self InjuryA. In the last year, the individual has, on 5 or more days,

engaged in intentional self-inflicted damage to the surface of his or her body, of a sort likely to induce bleeding or bruising or pain (e.g., cutting, burning, stabbing, hitting, excessive rubbing), for purposes not socially sanctioned (e.g., body piercing, tattooing, etc.), but performed with the expectation that the injury will lead to only minor or moderate physical harm. The absence of suicidal intent is either reported by the patient or can be inferred by frequent use of methods that the patient knows, by experience, not to have lethal potential. (When uncertain, code with NOS 2.) The behavior is not of a common and trivial nature, such as picking at a wound or nail biting.

Non-Suicidal Self Injury

B. The intentional injury is associated with at least 2 of the following:1. Negative feelings or thoughts, such as depression, anxiety, tension, anger, generalized distress, or self-criticism, occurring in the period immediately prior to the self-injurious act.2. Prior to engaging in the act, a period of preoccupation with the intended behavior that is difficult to resist.3. The urge to engage in self-injury occurs frequently, although it might not be acted upon.4. The activity is engaged in with a purpose; this might be relief from a negative feeling/cognitive state or interpersonal difficulty or induction of a positive feeling state. The patient anticipates these will occur either during or immediately following the self-injury.

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